Insufficient Nursing Staff Leads to Unwitnessed Fall and Missed Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff during the overnight shift, resulting in inadequate care and supervision for residents. On the night in question, only two nurses and two nursing assistants were present to care for approximately 50 residents across three units on different floors. Staff interviews confirmed that this staffing level was insufficient, with one nurse responsible for two units and nursing assistants having to cover multiple units, leaving some areas temporarily unstaffed. The facility's own policy requires adequate staffing to ensure resident safety and to meet care needs, but this was not met during the shift reviewed. As a result of the staffing shortage, a resident with Parkinson's disease and a history of falls experienced an unwitnessed fall in their room and remained on the floor for about an hour before being found. The resident required assistance for transfers and reported pain after the fall. Staff noted that the unsafe staffing ratios contributed to the incident and that residents requiring two-person assistance for care and transfers were not adequately supported. Another resident, dependent on staff for activities of daily living and requiring two-person assistance for transfers, did not receive scheduled morning medications, including a cardiac medication, due to the lack of available staff. Multiple complaints were made to the Ombudsman and the Department of Health regarding insufficient staffing, with reports that residents were left alone and felt fearful. Staff interviews corroborated that the facility was frequently short-staffed, requiring assistance from staff in the assisted living section to help cover care needs. The documented events demonstrate that the facility did not meet the required standard for staffing to ensure resident safety and the completion of necessary care and medication administration.