Failure to Provide Sufficient Nursing and Nurse Aide Staffing During Influenza Outbreak
Penalty
Summary
The facility failed to provide sufficient licensed nurse and nurse aide coverage to meet resident needs, particularly during an influenza outbreak. On one unit, only one Registered Nurse was responsible for all 58 residents in the facility overnight, resulting in missed medications and lack of resident monitoring. The facility's staffing records showed that only one nurse was present from approximately midnight to 7:00 AM, and there was no documentation of efforts to secure additional coverage after a nurse called in sick. Interviews with staff confirmed that the on-call nurse was also ill and unable to work, and that administrative staff, who were not licensed nurses, attempted to assist but could not provide necessary care or medication administration. Residents reported not receiving their scheduled morning medications, including pain medications, and staff confirmed that medication passes were missed. In addition to the nursing shortage, the facility failed to provide sufficient nurse aide staffing to ensure that residents received scheduled showers and baths. Documentation revealed that several residents missed multiple scheduled showers or baths over the course of a month, and both residents and staff reported that there were not enough CNAs to complete all required bathing care. Interviews with CNAs and LPNs indicated that staffing levels were inadequate to meet resident needs, especially on shower days, and that management was aware of the ongoing problem. The Director of Nursing and Administrator both acknowledged that CNA staffing shortages and high resident acuity were persistent issues, particularly on weekends. The facility's policies and facility assessment did not provide adequate detail on staffing needs by shift and by unit, nor did they include a specific contingency plan for staffing emergencies. The facility lacked a current policy for contingency or emergency staffing and did not have a documented process for on-call procedures in the event of staff call-ins. During the influenza outbreak, the facility did not activate its emergency plan or utilize agency staff, and no updates were made to the contingency plan following the incident. The Medical Director was not informed of the staffing shortage during the outbreak and stated that additional staff should have been provided given the increase in resident acuity.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.