Failure to Provide Adequate Nursing Staff Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in multiple residents not receiving their scheduled medications. On a specific day, there was no nurse assigned to the 200-hall during the day shift, which led to at least four residents missing their morning and afternoon medications. Medication administration records for these residents showed blank entries for the scheduled times, and interviews confirmed that the residents did not receive their medications as ordered. The affected residents had complex medical histories, including conditions such as spina bifida with hydrocephalus, epilepsy, schizophrenia, and various chronic illnesses requiring consistent medication management. Residents reported not seeing a nurse on the 200-hall during the day and only receiving care from nurses from other halls for personal needs, not medication administration. Staff interviews corroborated that there was a call-in and no nurse coverage for the 200-hall, and instructions to have another nurse cover the hall were not followed. The lack of nurse coverage was not identified or addressed in a timely manner, resulting in missed medication doses for all affected residents. Some residents reported no ill effects, while one resident described feeling moody and tearful due to the missed medications. The facility's staffing policy required adherence to state staffing formulas and adjustment based on resident needs, but this was not met on the day in question. The medication administration policy also required documentation and physician notification when medications were not given, but these procedures were not followed. The facility assessment tool indicated the required number of nursing staff, but the actual staffing did not meet these requirements, directly leading to the deficiency.