Insufficient Nursing Staff Resulting in Missed Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as required by their own facility assessment and regulatory standards. On multiple occasions, the number of Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) scheduled for shifts fell below the minimums documented in the facility assessment. For example, on several evening and night shifts, the facility was short by several CNAs and LPNs compared to the required staffing levels. The facility assessment itself was not properly signed or reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee, and staff responsible for scheduling were unaware of the minimum staffing requirements outlined in the assessment. Due to these staffing shortages, there were documented instances where residents did not receive their prescribed medications, including critical drugs such as antibiotics, anticoagulants, insulins, and psychotropics. Interviews with residents confirmed that there were times when no nurse was present on their unit to administer medications, and some residents reported these issues to administration and during resident council meetings. Staff interviews corroborated these findings, with CNAs and LPNs reporting frequent understaffing, the need to split coverage across multiple units, and being mandated to work overtime or double shifts due to inadequate staffing. Administrative staff, including the Staffing Coordinator, Director of Staff Resources, Director of Nursing, and the Administrator, acknowledged the ongoing staffing issues and confirmed that units were often left without adequate nurse coverage. The Director of Nursing and Administrator both stated that the facility sometimes had to split nurses between units or have supervisory staff pass medications when regular staff were unavailable. The Union President and other staff also reported that complaints about short staffing and missed medications were common, particularly on the overnight shift.