Failure to Provide Sufficient Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of residents on the [NAME] unit during the day shift on 12/25/24. On that day, only one nurse was present to care for 54 residents, despite facility policy and staff statements indicating that two nurses are required for this shift. The night shift nurse, who had already worked 16 hours, remained until approximately 9:30 a.m. but did not provide resident care or administer medications between 7:00 a.m. and 9:30 a.m., instead attempting to find coverage for the absent second nurse. As a result of the staffing shortage, several residents experienced delays in the administration of their scheduled medications. For example, one resident with orders for pseudoephedrine, baclofen, azelastine, and magnesium oxide received these medications several hours after their scheduled times. Another resident with orders for hydralazine and brimonidine tartrate also received medications later than scheduled. A third resident with orders for tramadol and Miralax experienced similar delays in medication administration. Interviews with staff confirmed that only one nurse was present during the day shift, and the nursing scheduler was unable to verify the intended schedule for that day due to limitations in the scheduling system. The administrator was made aware of the concern, and the facility's policy states that sufficient numbers of staff with the necessary skills and competency are to be provided in accordance with resident care plans and the facility assessment. No further information was presented prior to exit.