Failure to Maintain Sufficient Staffing Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by an incident involving a resident who was quadriplegic, ventilator-dependent, and fully reliant on staff for all care. On the evening in question, the resident experienced an unwitnessed fall from bed resulting in a nasal fracture. Staff interviews and record reviews revealed that only three nursing assistants (NAs) were present on the unit during the shift, despite the facility's own staffing guidelines requiring four to five NAs for that shift. Staff reported being overwhelmed and unable to provide adequate supervision, particularly when multiple staff were occupied with another dependent resident, leaving the rest of the unit unsupervised. Further review showed that the facility's assessment did not specify the average number of staff required to meet resident needs, and management was aware of the staffing shortfall but did not adjust assignments accordingly. The facility was unable to provide evidence that staffing was adjusted based on resident acuity or that their own guidelines were followed. As a result, the resident, who required total assistance, was left without adequate supervision, leading to the fall and injury.