Failure to Provide Sufficient Nursing Staff Resulting in Missed Medications and Inadequate Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents, particularly on the locked memory care and Transitional Units. On multiple occasions, only one nurse was assigned to cover both units simultaneously, with only one other staff member present on each unit. This staffing pattern resulted in missed medication administration for a group of residents on the Transitional Unit across numerous shifts, as documented in the facility's daily staffing sheets and confirmed by staff and resident interviews. The facility's own policy required adequate staffing based on census, acuity, and resident diagnoses, and mandated a licensed nurse to serve as charge nurse on each shift. However, review of staffing records over several weeks showed repeated instances where only one RN or LPN and two or three CNAs were present for up to 49 residents, with some shifts having even fewer staff. As a result, scheduled medications at various times (including 8:00 P.M., 9:00 P.M., 5:00 A.M., and others) were not administered to at least 13 residents on the Transitional Unit. Staff interviews corroborated that there were times when no nurse or CMT was present on the unit, and CNAs were left alone or had to leave their assigned unit to assist elsewhere, leaving residents unattended. Resident and staff interviews further confirmed the impact of insufficient staffing. One resident reported not receiving medications due to the absence of a nurse, and several CNAs described being the only staff on the unit or having to cover both units, resulting in residents not being checked as required. The DON and AIT acknowledged awareness of missed medication passes and insufficient staff to manage resident behaviors and ensure safety. The facility's failure to maintain adequate staffing directly led to unmet resident needs, including missed medication administration and lack of supervision.