Failure to Provide Sufficient Night Shift Staffing Resulting in Resident Death
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and ensure the supervision of residents, resulting in a deficiency related to inadequate staffing. On the night in question, only one nurse was on duty for the entire building, with one QMA assigned to three units and one CNA assigned to two units. This staffing pattern was not unusual for the facility, despite a census of approximately 93 to 97 residents. Staff interviews revealed that residents were not checked on every two hours as expected, and some staff did not physically enter certain residents' rooms, relying instead on residents to seek help if needed. Documentation and care records for one resident showed a lack of entries for toileting and other care after a certain time, indicating that required checks and assistance were not provided throughout the night. A resident with multiple chronic conditions, including COPD, congestive heart failure, diabetes, and heart disease, was found deceased on the floor between the bed and wheelchair during morning rounds. The resident had previously indicated a desire for CPR in the event of cardiac arrest, but was found with irreversible signs of death, and CPR was not initiated. Staff statements confirmed that the resident was not checked on during the night shift, and the last known interaction was the previous evening. The CNA assigned to the resident's unit had worked a double shift and did not perform the expected two-hourly checks, citing difficulty managing the workload. Other staff corroborated that night shift staffing was consistently low, making it challenging to provide timely care and supervision. The facility's own assessment and staffing model indicated a need for more licensed nurses and nurse aides per unit than were actually scheduled, and the assessment lacked documentation of how policies and procedures were evaluated or updated. Multiple staff and residents reported that the number of staff on night shift was insufficient to meet care needs, with delays in response to call lights and medication requests. Staffing schedules showed frequent instances of only one nurse on duty, with no documentation of efforts to secure replacements when staff called in. The deficiency was identified as immediate jeopardy due to the failure to provide adequate care and supervision, resulting in a resident not being checked on all night and subsequently being found deceased.