Failure of Administration, Staffing, and Abuse-Prevention Systems Creating Immediate Jeopardy
Penalty
Summary
The deficiency involves the Nursing Home Administrator (NHA) and Director of Nursing (DON) failing to fulfill their essential job duties related to resident safety, staffing, and abuse prevention. According to their job descriptions, the NHA was responsible for leading and directing facility operations in accordance with regulations and facility policies, performing rounds to observe residents, and promoting an environment of trust focused on resident safety and abuse prevention. The DON was responsible for planning, organizing, and directing nursing services, ensuring adequate staff coverage, performing rounds to ensure nursing needs were met, and monitoring for allegations of potential abuse or neglect and participating in investigations. Surveyors determined that the NHA and DON failed to timely and effectively manage 12 allegations of resident neglect and failed to maintain sufficient nursing staff to provide resident care and treatment, resulting in an Immediate Jeopardy situation for 12 of 12 identified residents (R1–R12). These failures were identified through review of job descriptions, clinical records, observations, and staff interviews. The facility also failed to ensure required abuse and neglect prevention measures and staff screening processes were in place and documented. Annual abuse and neglect prevention training was not completed for five of seven reviewed staff members (two NAs, two RNs, and the DON), and the facility could not provide documentation of annual abuse and neglect training for all 90 current employees for an entire 12‑month period. In addition, the facility failed to complete a pre‑employment criminal background check for one LPN and failed to verify current, valid licenses and check for disciplinary actions with licensing and registration boards for five of seven reviewed employees (two NAs, two RNs, and the DON). These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all 66 residents in the facility. The NHA and DON were formally notified by surveyors that their failures created Immediate Jeopardy conditions affecting both the 12 residents associated with neglect allegations and the entire resident population.
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