Facility Assessment Failed to Reflect Actual Staffing, Leading to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately reflected the resources and staffing needed to care for residents, as required. The assessment, reviewed by Quality Assurance and Performance Improvement, documented that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets for multiple dates over approximately one month showed that several units, including the rehabilitation, long-term, and dementia units, were often staffed with only one nurse per unit during the day shift, despite each unit housing about 30 residents. This staffing pattern was observed repeatedly, and on several occasions, a single nurse was responsible for medication administration and resident care, which led to medications being administered late. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed that the actual staffing did not match the facility assessment. 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 called for 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 any habitual lateness among nurses, but the discrepancy between the assessment and actual staffing contributed to delays in medication administration.