Failure to Provide Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as outlined in its own facility assessment. The assessment, reviewed by Quality Assurance and Performance Improvement, specified that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets and direct observations revealed that on multiple dates, including the observed date, only one nurse was assigned per unit, each responsible for approximately 30 residents. This staffing pattern was consistent across several dates within a one-month period for all units, including the rehabilitation, long-term, and dementia units. As a result, there were instances where medications were administered late due to the insufficient number of nurses available to provide timely care. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed the discrepancy between the facility's staffing plan and actual staffing practices. Staff reported frequently working alone on units, and the staffing coordinator acknowledged that units were sometimes staffed with only one nurse if additional staff were unavailable. The interim DON and administrator both agreed that the facility assessment required two nurses per unit on the day shift, but staffing records showed this was not consistently achieved. There was no indication that staff were aware of habitual lateness among nurses, but the lack of adequate staffing directly contributed to delays in medication administration and did not align with the facility's documented plan.