Insufficient Nursing Staff Leads to Missed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in missed essential medical care and unaddressed physician orders for two residents. One resident, with diagnoses including end stage renal disease and heart failure, missed scheduled dialysis appointments on two occasions due to the facility's failure to timely enter physician orders and ensure transportation to dialysis. This led to the resident being sent to the hospital for emergent dialysis after presenting with a critical venous oxyhaemoglobin level. Facility records did not show documentation of the resident's leave of absence for dialysis as ordered. Another resident, admitted with respiratory failure, immunodeficiency, and kidney transplant rejection, did not have a required follow-up appointment with a transplant surgery office scheduled, as ordered in the hospital discharge summary. The RN Supervisor, responsible for scheduling such appointments, confirmed the delay was due to staffing issues. Additionally, new nursing staff reported not being assigned a preceptor or mentor, and the RN Supervisor was observed performing multiple roles, including medication administration and supervisory duties, due to lack of available staff. Interviews with staff and review of staffing sheets revealed that the facility often had only one nurse assigned to a floor, with the RN Supervisor covering both supervisory and direct care roles. The DON and NHA confirmed that the facility did not have enough nursing staff scheduled, and that nurses frequently called off, with no agency nurses used to fill gaps. These staffing shortages directly contributed to the failure to provide necessary care and services to residents as required by regulation.