Failure to Provide Sufficient Staffing and 1:1 Monitoring in Secure Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in the secure male and female units, resulting in multiple resident-to-resident altercations and injuries. On several occasions, residents who required 1:1 monitoring due to behavioral risks did not have a designated staff member assigned to them, as required by the facility's own in-service training and stated procedures. Instead, existing CNAs were expected to rotate or attempt to monitor these residents in addition to their regular duties, despite being responsible for large numbers of residents with known behavioral issues. This lack of dedicated staffing led to incidents where residents were left unsupervised, resulting in physical altercations, falls, and injuries such as skin tears and lacerations. Specific incidents included a male resident with severe cognitive impairment and a history of physical aggression who was placed on 1:1 monitoring after an altercation, but no additional staff was assigned. This resident subsequently assaulted another resident, causing a fall and injury, while unsupervised in the dining room. Similarly, in the female secure unit, a resident with a traumatic brain injury and severe cognitive impairment was involved in multiple altercations, including grabbing and slapping other residents, while supposed to be on 1:1 monitoring. Staffing records and interviews confirmed that no extra staff were provided for 1:1 monitoring during these times, and CNAs reported being unable to maintain required supervision due to being the only staff on the unit or having to cover both secure units simultaneously. Interviews with staff, including CNAs and nurses, revealed that it was common practice for the facility to operate with fewer staff than required, especially during night shifts, and to rely on existing staff to provide 1:1 monitoring without relief. The Director of Nursing and Assistant Director of Nursing acknowledged that additional staff should be assigned for 1:1 monitoring but were unaware of instances where this did not occur. The facility did not have a formal staffing policy, and documentation showed that 1:1 monitoring sheets were often signed by staff already assigned to the unit, rather than by a dedicated monitor. These failures were confirmed through observation, record review, and staff interviews.