Failure to Provide Sufficient Nursing Staff Resulting in Delayed and Missed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of multiple residents, resulting in the late or missed administration of scheduled medications, particularly insulin for residents with diabetes. Medication Administration Records (MARs) for several residents showed repeated instances where insulin and other medications were administered late or not at all over the course of two months. For example, one resident with diabetes and moderate cognitive impairment had insulin doses administered late or missed on numerous occasions, while another resident with diabetes and no cognitive impairment experienced similar delays and omissions in insulin administration. Interviews with residents and staff confirmed the ongoing issue of short staffing, with both regular and registry (temporary) nurses struggling to manage medication administration and resident care. Residents reported receiving medications late, sometimes after meals instead of before as prescribed, and described feeling unwell as a result. Staff interviews revealed that the facility was often operating with only one nurse per station, and that the absence of key leadership positions such as the Director of Nursing and Director of Staff Development exacerbated the problem. Staff also noted that registry nurses were frequently unfamiliar with residents' routines, leading to inconsistent care and further delays. Facility documentation and staff statements indicated that the facility was aware of the need to match staffing levels and competencies to resident needs, including those with complex conditions such as diabetes. However, the ongoing reliance on registry staff, frequent staff turnover, and lack of adequate supervision resulted in the facility's inability to consistently administer medications as scheduled. This failure decreased the facility's potential to safely meet residents' needs and promote their physical well-being, as evidenced by the direct impact on residents' medication schedules and reported well-being.