Insufficient Nursing Staff Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically on the 500 hall/unit, resulting in the inability to administer medications as ordered for 17 out of 24 residents reviewed. Record review and staff interviews revealed that when nurses called out, the procedure was to notify the Staffing Coordinator or Administrator. Despite attempts by the Staffing Coordinator to contact off-duty nurses and inform the Administrator and interim DON, there were instances where no additional nurses could be secured to cover the shift. As a result, scheduled medications were not administered as prescribed by physicians. Further interviews with the Unit Manager indicated that when short staffed, she would attempt to adjust the schedule or notify appropriate leadership. If unable to secure additional staff, the expectation was that the Unit Manager or Supervisor would take a medication cart to administer medications. However, on the dates in question, there was no nurse assigned to administer medications on the 500 hall, leading to significant medication errors for multiple residents. The deficiency was substantiated by cross-references to related tags regarding medication administration failures.