Insufficient Nursing Staff on Secured Dementia Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on the secured dementia unit for all 13 residents residing there. Observations showed that at various times, only one nurse and one or two CNAs or QMAs were present on the unit, with staff often occupied in different areas, leaving residents unattended. Several residents required extensive or total assistance for transfers and toileting, and many were at risk of falling. During periods when staff were assisting one resident or were off the unit, other residents were left without supervision, increasing their risk of falls and unmet care needs. Staff interviews confirmed that staffing was reduced from three to two staff members during the late afternoon and overnight shifts, coinciding with times when residents were more likely to experience increased confusion and agitation due to sundowner's syndrome. A review of the staffing schedule and clinical records indicated that the unit was consistently staffed with three nursing staff from 7:00 a.m. to 3:00 p.m., but only two staff from 3:00 p.m. to 7:00 a.m., despite the high level of assistance required by residents. Between 5/1/24 and 5/7/25, there were 53 falls among the 13 residents, with 39 of those falls occurring during the lower-staffed hours. The facility's own assessment tool stated that resident care needs and negative outcomes should be considered in staffing decisions, but the observed staffing levels did not meet the needs of the residents on the secured dementia unit.