Inadequate Night Shift Nursing Coverage for Facility Census
Penalty
Summary
On the night shift of 5/4/25, the facility failed to provide adequate nursing staff for a census of 72 residents, as only one licensed nurse was present for the entire shift after the second nurse clocked out at 12:25 a.m. Multiple staff interviews confirmed that this staffing shortage was not a safe practice and could compromise residents' safety, particularly in emergency situations such as a code blue. Staff also expressed concerns that one nurse would be unable to handle emergencies, administer medications as scheduled, or meet residents' needs effectively during the shift. Record reviews and interviews with the Staffing Coordinator and Director of Nursing confirmed the staffing shortage and acknowledged that attempts were made to fill the gap, but were unsuccessful. The facility's own assessment tool and job descriptions emphasized the need for sufficient staffing to meet residents' needs, but these guidelines were not met on the night in question, potentially impacting the health and well-being of all residents in the facility.