Failure to Provide Adequate Staffing and Maintain Valid RN Licensure
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, specifically for those requiring assistance with bed mobility and mechanical lift transfers. One resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop, was dependent on staff for bed mobility and transfers. The resident's care plan required substantial or maximal assistance of two persons and the use of a sit-to-stand mechanical lift for transfers and repositioning. However, interviews and observations revealed that staff routinely performed these tasks alone, without the required second person, and staff reported being assigned to care for 14 to 18 residents per shift, making it difficult to comply with care plans and ensure resident safety. Multiple staff members confirmed that they often performed two-person transfers alone due to insufficient staffing, and that it was challenging to find assistance from other staff, including nurses who were occupied with other duties. Staff described situations where they had to physically move residents by themselves or seek help from ancillary staff, some of whom had expired credentials. Staff also reported that the nurse assigned to the unit was frequently unavailable to assist with transfers, and that the overall workload was too high for the number of staff present. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a valid RN license authorizing them to work in the state. The DON's multi-state RN license had expired, and a temporary license issued in another state did not permit practice in the facility's state. This lapse in licensure was confirmed by both the state licensing board and the DON, who was unaware that the temporary license was not valid for practice in the facility's state. The administrator was informed of the invalid credentials and confirmed the need for a current state or multi-state license for the DON role.