Inadequate Staffing Leads to Resident Elopement and Lapses in Supervision
Penalty
Summary
The facility failed to provide an adequate number of nursing staff to meet the needs of all residents, as evidenced by an incident where a resident eloped from the male locked memory care unit. On the night of the elopement, staffing was insufficient, with only one CNA present on the relevant hall while the other CNA was on break, and the LPN was responsible for multiple areas. Staff interviews confirmed that the nurse was unaware of the staffing shortage at the time, and the CNA present had hearing issues and did not respond to the alarm, mistaking it for a recurring door issue. The facility's staffing policy requires sufficient licensed and unlicensed staff on each shift, but the actual staffing levels did not meet this standard during the incident. Observations also revealed that a nurse was found sleeping during a shift, and staff reported challenges in managing multiple halls and responding to alarms due to inadequate staffing. The administrator stated she had not observed staff sleeping during her visits, but the incident reports and staff interviews indicate lapses in supervision and response. The facility census documented 76 residents at the time, all potentially affected by the staffing deficiencies.