Chronic Understaffing Leads to Delayed Medication and Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delayed medication administration and inadequate assistance with activities of daily living. Observations during the survey period revealed that staff members, including nurses and aides, were consistently unable to complete their assigned duties in a timely manner due to chronic understaffing. Nurses were responsible for passing medications in multiple units, often resulting in medication passes being out of compliance with required administration windows. Aides were tasked with multiple responsibilities, including meal preparation, serving, cleaning, and laundry, in addition to direct resident care, which further contributed to delays and incomplete care. Multiple residents with complex medical needs, such as diabetes requiring scheduled insulin administration, experienced repeated delays in receiving their medications. Medication Administration Records (MARs) for several residents documented numerous instances where insulin and other medications were administered significantly later than ordered, sometimes by several hours. Residents and staff interviews corroborated these findings, with reports of medications being given late at night or well past the scheduled times, and residents having to wait extended periods for assistance with transfers or toileting, especially those requiring two-person assistance or mechanical lifts. Staff interviews indicated that float aides, intended to provide additional support, were frequently unavailable due to call-ins, leaving only one aide per unit and one nurse covering multiple units. This staffing pattern made it difficult to ensure timely care, particularly for residents at high risk for falls or those requiring extensive assistance. The facility's staffing sheets confirmed frequent changes in staffing patterns and instances where only one nurse was available for several units, further exacerbating the delays in care and medication administration. Residents expressed frustration and concern over the delays, and staff reported an inability to complete essential care tasks, resulting in missed showers, incomplete cleaning, and delayed or missed medication doses.