Failure to Provide Adequate Nursing Staff Resulting in Delayed Medication Administration and Insufficient Supervision
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive their medications in a timely manner and lacked appropriate supervision. Several residents with complex medical histories, including psychiatric disorders, diabetes, heart failure, and mobility issues, reported not receiving their evening or bedtime medications until several hours after the scheduled administration times, with some medications being given as late as 2:00 or 3:00 A.M. instead of the ordered 8:00 or 9:00 P.M. In some cases, residents did not receive their medications at all, and staff interviews confirmed that agency nurses were unfamiliar with residents and unable to manage the workload effectively. Documentation audits and resident interviews corroborated these delays and omissions, with residents expressing concerns about trust in night shift staff and the impact on their health and well-being. The staffing shortages were particularly acute during night shifts, where there were documented occasions of only one licensed nurse being responsible for up to 91 residents across both the skilled nursing facility and the attached assisted living unit. Staff and residents reported that call lights went unanswered for extended periods, residents did not receive timely assistance with activities of daily living, and treatments and hygiene care were not consistently performed. Observations revealed that nurses were pre-setting medications to expedite administration due to being overwhelmed with responsibilities, and dietary staff were assisting with tasks outside their scope, such as delivering meal trays without ensuring they were within residents' reach. The facility's own assessment indicated that the number of licensed nurses and CNAs on duty was insufficient to meet the care needs of the resident population, and the assessment did not account for the staffing needs of the attached assisted living unit. Multiple complaints and concern logs documented issues with grooming, call light response, toileting, and medication administration. Family members and staff described residents being left in soiled conditions, not receiving two-person transfers as required, and experiencing a decline in care quality. The facility was relying heavily on agency staff and had several open nursing positions, contributing to inconsistent care and supervision.