Failure to Provide Sufficient Licensed Nursing Staff Results in Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet the needs of all residents, as evidenced by interviews and record reviews for four residents with complex medical conditions. These residents reported that their scheduled evening medications, including pain management and other critical treatments, were frequently administered late. Residents described being woken up to receive medications well past the scheduled times, sometimes after midnight, resulting in increased pain and dissatisfaction. The issue was corroborated by the residents' cognitive status, as documented in their Minimum Data Set (MDS) assessments, and by their direct statements regarding the impact of late medication administration. Multiple staff members, including LPNs and the wound care nurse, confirmed that the reduction in evening nursing staff from four to three nurses between 6 PM and 10 PM made it difficult to complete medication passes on time. Staff reported that the change was made by facility ownership to save money, and that three nurses were insufficient to manage the medication needs of the resident population during the evening shift. The facility's own policy requires staffing levels to be based on resident census and needs, and the daily census showed 100 residents at the time of the survey. Resident Council meeting memoranda further documented ongoing concerns, with residents expressing frustration about waiting until after 11 PM for medications and call lights not being answered promptly. The Director of Nursing acknowledged awareness of the issue and the difficulty nurses faced in completing all required tasks with the reduced staffing. The administrator also confirmed that medication administration times were being documented as late, consistent with resident and staff reports.