Insufficient Staffing in Secured Memory Care Unit Leads to Increased Incidents
Penalty
Summary
The facility failed to provide sufficient staffing with the necessary competencies and skills to meet the behavioral health needs of all 14 residents in the secured memory care unit. Observations revealed that at various times, only one or two staff members were present to supervise and care for residents with severe cognitive impairments, including Alzheimer's disease and dementia. Staff were frequently occupied with individual resident care tasks, leaving other residents unsupervised, which led to situations where residents wandered, entered other residents' rooms, or engaged in unsafe behaviors such as pushing wheelchairs or fighting over snacks. Staff interviews consistently indicated that the staffing levels were inadequate to provide the required supervision and care, especially given the residents' high needs for assistance with activities of daily living (ADLs) and behavioral management. Incident logs showed a disproportionate number of accidents and behavioral incidents in the secured unit compared to the rest of the facility. Of the total incidents recorded since the beginning of the year, 40% involved the 14 residents in the secured unit, who made up only 22% of the facility's population. These incidents included physical aggression, exit-seeking, bruises, and both witnessed and unwitnessed falls. Staff reported that many falls and incidents occurred when they were busy assisting other residents, and that the lack of supervision contributed to increased wandering and aggression among residents. The activity staff, who were intended to provide engagement, were frequently interrupted to address behavioral issues due to the lack of available nursing staff. Interviews with staff, including CNAs, LPNs, the activity director, and the psychiatric physician's assistant, all highlighted the challenges posed by insufficient staffing. Staff expressed concerns about resident safety, the inability to provide adequate supervision, and the increased workload leading to burnout. The facility's own policy required staffing levels to be based on resident needs and care plans, but the increase in resident numbers in the secured unit was not matched by an increase in staff. Overnight shifts were particularly understaffed, with only one CNA assigned to the secured unit and two nurses for the entire facility. The deficiency was further corroborated by the experiences of responsible parties and staff who reported frequent falls, increased aggression, and a lack of engagement for residents due to inadequate supervision.