Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs and Medication Errors
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in unmet care needs across multiple units. Observations and interviews revealed that on several occasions, there was only one nurse and one certified nursing assistant (CNA) assigned to units with up to 40 residents. This staffing shortage led to residents not receiving essential care such as showers, assistance with eating, toileting, personal hygiene, and timely administration of medications. Multiple residents reported waiting extended periods for assistance, including one resident who waited over 24 hours for help after soiling their bed due to illness. Other residents were observed with unwashed hair, uncut nails, and unchanged soiled clothing for hours, and some were left in stool for over five hours. The lack of adequate staffing also resulted in significant medication errors, with audit reports confirming that over 190 residents did not receive multiple medications on several days. Staff interviews corroborated that medication passes were missed due to insufficient nursing staff, and the medical director confirmed that residents did not receive their medications timely or at all. The facility's own staffing records showed that on certain shifts, the staff-to-resident ratios were as high as one CNA or nurse for every 40 to 73 residents, far below the facility's stated minimums. Staff frequently reported being unable to provide more than minimal care, and residents requiring two-person assistance or mechanical lifts often remained in bed without care. Grievances and resident council meeting minutes documented ongoing complaints about lack of showers, delayed call light responses, and missed medications. Staff, including the staffing coordinator and DON, acknowledged the chronic understaffing and its impact on resident care. The facility's payroll and punch records further confirmed sporadic and inadequate staffing levels, particularly on weekends and during emergencies, such as weather-related events. These deficiencies were observed and verified by the survey team, leading to the declaration of Immediate Jeopardy due to the likelihood of serious harm or death for residents.
Removal Plan
- Staffing is evaluated and adjusted as needed at the beginning of each shift to meet needs and acuity of the resident population, and the facility assessment is updated to reflect changes such as the temporary closing of a resident unit to help meet staffing needs.
- The facility policy and procedure includes details for minimum and emergency staffing and if staffing levels fall below minimum, the Director of Nursing and Administrator are contacted for direction.
- All facility department heads, nursing supervisors and ancillary staff receive education related to the facility's emergency staffing plan prior to the start of their next scheduled shift.
- Staffing coordinator, nursing supervisors, nurse managers and the Minimum Data Set Coordinator verify receipt of education related to the emergency staffing plan.
- New hires include certified nursing assistants, licensed practical nurses, a licensed practical nurse unit manager, and a registered nurse admissions nurse.
- The facility provides staffing agency agreements.
- The facility plans events to increase staff morale and retention.
- Resident census and staffing numbers for each residential unit are verified and deemed appropriate to meet the care needs of the current resident population.