Neglect Due to Insufficient Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a resident who was neglected due to insufficient staffing during a bed mobility task. The resident, who was non-verbal and dependent on staff for all activities of daily living, required the assistance of two staff members for safe bed mobility. However, on the day of the incident, the facility was understaffed, with only one nurse and two CNAs available for the entire building. As a result, a CNA attempted to care for the resident alone, which led to the resident falling from the bed and sustaining a head injury that required hospital transfer. The CNA involved admitted to not asking for help despite knowing the resident required two-person assistance. The CNA attempted to manage the situation by lowering the bed and calling for help, but the resident still fell and was injured. The CNA acknowledged the mistake and attributed it to the lack of available staff, as the facility did not replace staff who called off that day. The incident highlighted a recurring issue of understaffing, which was acknowledged by other staff members who reported similar experiences of being unable to provide adequate care due to insufficient staffing levels. The facility's administration was slow to respond to the incident, with the Director of Nursing and Nursing Home Administrator only becoming aware of the situation days later. The care plan for the resident was not active at the time of the incident, which contributed to the confusion about the required level of assistance. The facility's policies on care planning and injury prevention were not effectively implemented, as evidenced by the unresolved care plan and the lack of timely reporting and investigation of the incident.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-600 Free From and Neglect Element #1: Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. No additional findings noted upon assessment and level at acceptable level for resident. Resident #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2: A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were affected by the alleged deficient practice. No other opportunities were identified. Element #3: Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4: The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5: Facility's Allegation of Compliance Date is , 20225.