Insufficient Nursing Staff Resulting in Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on both the first and second floors, resulting in delays in medication administration, untimely responses to residents' call lights, and inadequate supervision of nursing assistants. Observations and interviews revealed that nurses were responsible for covering multiple medication carts and had more residents assigned than they could manage, leading to late medication passes. The electronic Medication Administration Record (eMAR) frequently showed residents' medications as late, and staff reported being unable to complete their duties on time due to being short-staffed. Multiple staff members stated that when only two nurses were present on a unit, they could not provide timely care, supervise aides, or monitor residents' conditions adequately. Residents reported consistently receiving their medications late and experiencing long wait times for assistance after activating their call lights. Some residents stated they had to wait up to an hour or more for help, and in some cases, had to walk to the nurses' station themselves. Grievance forms and interviews with residents and family members corroborated these issues, with reports of residents having to yell for help, waiting extended periods for pain medication, and staff acknowledging the ongoing staffing shortages. Review of facility assignment sheets over a one-month period confirmed that numerous shifts on both floors operated with only two nurses, and nurses were often required to share medication carts. The staffing coordinator indicated that nurse shifts were being cut due to a lower census, but the remaining residents, particularly those in rehab, required more assistance. Despite staff raising concerns to management and the staffing coordinator, no additional support was provided, and the staffing shortages persisted, directly impacting the timeliness and quality of resident care.