Failure to Provide Sufficient Nursing Staff for Resident Care and Timely Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of several residents, as evidenced by direct observations, interviews, and record reviews. One resident, who required substantial assistance with personal hygiene and toileting due to incontinence, was left with a call light on for over an hour and a half without receiving incontinence care. The resident reported that their incontinence brief had not been changed since the previous night, and staff confirmed that there was inadequate staffing on the unit, with only one nurse and 1.5 CNAs available for a heavy long-term care unit. The resident's medications were also administered over an hour late due to staffing shortages. Another resident, who was cognitively impaired and required substantial assistance for personal hygiene and toileting, remained in a wheelchair in the dining room for several hours without being changed or toileted. The CNA responsible for this resident was also assigned to another unit and had not yet provided incontinence care, stating that he had been too busy with other residents. Staff interviews confirmed that residents were not being toileted or changed every two hours as required. A third resident did not receive scheduled medications on time, with administration occurring nearly two hours late. The LPN responsible stated she was the only nurse on the unit and was unfamiliar with the residents, working on a PRN basis. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and that the goal was to meet state staffing requirements and resident care needs. The facility's policy requires sufficient staff to ensure resident safety and well-being, but observations and staff statements indicated that staffing levels were inadequate to meet these standards.