Failure of Governing Body to Ensure Administrative Oversight and Resident Safety
Penalty
Summary
The facility's governing body failed to provide effective oversight and ensure that systems were in place to protect resident health and safety during a period when the facility operated without an assigned administrator. During this time, three Immediate Jeopardy situations occurred involving three residents. The facility did not maintain administrative oversight or monitoring systems, resulting in failures to notify physicians and responsible parties of significant changes in resident conditions, to complete required neurological checks after a fall with head injury, and to address repeated refusals of psychotropic medications for a resident with dementia and bipolar disorder. One resident, an elderly female with multiple complex medical conditions including a seizure disorder, experienced a seizure in the morning. The facility failed to promptly notify her physician and family, only sending a message to the physician in the afternoon and not informing the family until later that evening. There was no documentation of neurological monitoring or post-seizure assessment, and no evidence of follow-up physician involvement. Another resident, newly admitted with diabetes and hyperlipidemia, sustained an unwitnessed fall with a head strike and required sutures. There was no documentation of the fall in nursing progress notes, no incident report, no ER records filed, and no evidence of neurological monitoring upon her return to the facility. A third resident with severe cognitive impairment, dementia, and bipolar disorder had ongoing refusals of dementia and psychiatric medications over approximately eight weeks. Despite repeated refusals, there was no evidence of physician notification, follow-up psychiatric evaluation, or care plan interventions addressing the refusals. The resident's untreated conditions escalated to behavioral crises, resulting in transfer to a psychiatric hospital. Interviews with staff and leadership revealed confusion about who was acting as administrator, lack of clear communication, and uncertainty about who was responsible for abuse/neglect reporting and administrative oversight during the period without an assigned administrator.