Administrative and Clinical Oversight Failures Leading to Resident Exit Through Second-Floor Window
Penalty
Summary
Facility administration, including the NHA and DON, failed to effectively manage operations to ensure resident safety and maintain residents’ highest practicable physical and mental well-being. The NHA’s job description required directing day-to-day facility functions in accordance with federal, state, and local regulations to ensure quality care, and the DON’s job description required organizing and directing nursing services and resident care. Despite these responsibilities, the facility did not ensure the environment was maintained as free of accident hazards as possible, did not ensure adequate supervision and environmental safety, and did not ensure consistent implementation of facility policies related to resident safety. The facility also failed to ensure that windows were secured to reduce environmental hazards, leaving additional windows unsecured and placing residents at risk for falls and self-harm. The facility further failed to ensure appropriate management and oversight of a resident’s psychiatric care and medication regimen. For one sampled resident with known psychiatric conditions, including suicidal ideation and worsening depression, the facility did not maintain an effective system to identify and mitigate risks. This included failure to ensure appropriate oversight of psychiatric treatment and medication management, such as ensuring that prescribed drugs were given in the correct dose, at the correct time, and monitored for effectiveness and side effects. As a result of these failures, the resident was able to exit the facility through a second-floor window and land on a porch into the snow. These deficiencies were cited as Immediate Jeopardy under F689 (Accidents, 42 CFR §483.25(d)) and related Pennsylvania regulations, based on the lack of effective administrative oversight, monitoring, and enforcement of policies by facility leadership.
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