The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
The NHA and DON failed to manage diabetes care consistent with standard nursing practices. The facility did not notify physicians of elevated or decreased CBG levels, did not assess residents for hyperglycemia or hypoglycemia, and did not ensure insulin was given according to physician orders and manufacturer instructions for multiple residents. The report states these failures involved eight residents and resulted in immediate jeopardy.
Failure to Supervise Resident Resulting in Elopement: The NHA and DON failed to effectively manage the facility by not ensuring proper supervision for a resident, resulting in an elopement event. The report states the resident exited to an unsupervised and unauthorized location without staff knowledge, and the event created an immediate jeopardy situation for all residents identified as elopement risk.
The NHA and DON failed to effectively manage the facility to ensure residents were free from abuse and to ensure abuse policies were implemented. Their job descriptions required them to direct daily operations in accordance with federal, state, and local standards to assure the highest degree of quality care, but the report states the facility failed to provide fundamental principles of treatment and care and failed to ensure care was delivered in accordance with professional standards and facility policies, resulting in an IJ situation.
The NHA and DON failed to effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement. Facility records and job descriptions showed the NHA was responsible for maintaining effective systems and overseeing staff, care, supplies, and facilities, while the DON was responsible for nursing management, resident care standards, policy implementation, and supervision of the nursing department. The report states the facility failed to properly supervise a resident and failed to respond appropriately to the elopement.
The NHA and DON failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility did not have working laundry equipment to ensure clean and sanitized linens and laundry, and this was identified as an Immediate Jeopardy for all 67 residents. The NHA and DON confirmed the failure during interview.
A resident eloped from the facility after staff failed to ensure proper supervision, and the event was identified as an IJ for all residents at risk for elopement. The NHA and DON were found to have failed to effectively manage the facility and to fulfill their job duties related to overseeing operations and nursing services.
The NHA and DON did not effectively manage the facility when residents who smoked were allowed to keep smoking materials unsecured in their rooms and on their person. Survey findings showed the facility lacked a system to monitor and account for smoking materials for residents approved to smoke during leaves of absence, and this was cited as an IJ.
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