Insufficient Nursing Staff Leads to Unmet Resident Care Needs
Penalty
Summary
The facility was found to have insufficient nursing staff to provide necessary nursing and related services, impacting the well-being of six residents. The deficiency was identified through a review of facility policies, resident observations, and interviews with residents and staff. The facility's job descriptions for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) require accurate administration of medication and treatments per physician orders, along with comprehensive documentation. However, the facility failed to meet these requirements due to a lack of available staff. Specific instances of this deficiency include a resident not being weighed as ordered because a Certified Nurse Aide (CNA) was unavailable, and multiple residents not receiving ordered wound care treatments due to various reasons such as other patient care demands, unknown completion by the wound care nurse, and lack of assistance. The Director of Nursing confirmed the facility's failure to maintain sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Plan Of Correction
R1, R8, R22, R60, R81, R90 medical records are unable to be altered. R1 weight remained stable. R8 was discharged from the facility. R22 wound remains stable. R60 was discharged home. R81 is no longer at the facility. R90 was discharged from the facility. No resident experienced adverse effects related to the staffs documentation in the medical record. The facility staff identified will be provided disciplinary action per handbook. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated the NHA/DON on regulatory requirements of F725 licensed nursing staff education on what to do if unable to complete an assigned task. The DON/designee will audit the facility activity report to review any omissions of care and follow up as appropriate 2 times per week x 4 weeks then monthly X 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.