Failure to Provide Adequate Nursing Staff Resulting in Delayed Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations and staff interviews. On the morning in question, several CNAs were sent home after testing positive for COVID-19, leaving only one CNA to cover an entire wing that typically required four. As a result, food trays for residents requiring transmission-based precautions remained unattended on carts for extended periods, with some residents not receiving their meals until significantly later than scheduled. Staff confirmed that the shortage prevented timely meal delivery and that residents would eventually be fed, but not according to the usual schedule. Additionally, the staffing shortage impacted medication administration. One resident, who was cognitively intact and had a diagnosis of arthritis, did not receive scheduled pain medication (Norco) until more than two hours after the scheduled time. The nurse responsible for medication administration reported being delayed due to the need to reorganize CNA assignments after the staffing shortage, and did not notify supervisory staff for assistance. This delay was confirmed by both the resident and staff involved in the medication pass. The lack of sufficient staff also affected personal care. Another resident, admitted with a history of stroke, did not receive a scheduled shower due to the staffing shortage, as confirmed by the CNA assigned to the wing. The staffing coordinator and DNS both stated they were not notified of the shortage until later in the morning, and the administrator, who was responsible for coordinating additional staffing, was not made aware of the issue until after the shortage had already impacted resident care.