Delayed Medication and Enteral Feeding Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate skill sets to meet the needs of all residents, as required by facility policy and state regulations. On a specific date, there was only one nurse available for the entire building during the 3:00 p.m. to 11:00 p.m. shift, resulting in significant delays in the administration of medications and enteral feedings. Clinical records showed that one resident's enteral feeding, scheduled for 4:00 p.m., was not started until 9:42 p.m., and their Lispro Insulin, ordered before dinner at 5:00 p.m., was also delayed until 9:42 p.m. Another resident's enteral feeding, also scheduled for 4:00 p.m., was not started until 10:24 p.m., and a third resident's feeding, scheduled for 6:00 p.m., was delayed until 7:46 p.m. Multiple staff interviews confirmed that the delays were directly related to short staffing on the identified date. The only nurse on duty during the affected shift was responsible for all medication cart keys and the care of all residents, which contributed to the significant delays in medication and feeding administration. The Nursing Home Administrator also confirmed that the staffing shortages led to these delays for the affected residents.