Failure to Provide Sufficient Nursing Staff Resulting in Missed and Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on a specific day when one licensed nurse called off and another was a no call no show, resulting in the inability to administer scheduled medications to multiple residents at the designated times. This staffing shortage directly led to four residents not receiving their scheduled 9:00 a.m. medications, as documented in their Medication Administration Records (MARs). Additionally, one resident's medication for breast cancer was administered late on multiple occasions throughout the month, as shown in the Administration Details Report. Resident records reviewed indicated that the affected individuals had significant medical histories, including conditions such as stroke, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. These residents required moderate assistance with activities of daily living and had intact cognition. Interviews with the residents confirmed that medications were not administered on time, with some reporting delays of several hours and expressing concern and distress over the missed or late doses. The Director of Nursing (DON) acknowledged responsibility for managing the licensed nurse schedules and stated that she should have covered the shift when the staffing shortage occurred. Facility policy and the DON's job description both require ensuring sufficient and competent staffing to meet resident needs, but these requirements were not met on the day in question, resulting in the observed deficiency.