Insufficient Overnight Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff on the One East Unit during the overnight shift, resulting in only one nursing assistant (NA) and one nurse being present to care for 24 residents. This staffing level was below the facility's own minimum requirement of one nurse and two NAs for the unit. Staff interviews confirmed that management was aware of the unsafe staffing situation, and the Assistant Director of Nursing Services acknowledged that staffing with less than two NAs would not be safe, especially for residents requiring lifts for transfers. Record review showed that only nine NAs worked in the facility that night, which was below the required minimum for all units combined. Two residents on the unit were directly affected by the staffing shortage. One resident, admitted with dementia, lack of coordination, and a history of falls, required maximum assistance with toileting, hygiene, and transfers using a mechanical lift, as well as frequent checks to prevent skin breakdown. This resident experienced multiple falls during their admission. Another resident, admitted with a history of stroke and schizoaffective disorder, was incontinent, required maximum assistance with hygiene, had impaired mobility, and had a stage two pressure ulcer requiring repositioning at least every two hours. This resident also experienced multiple falls and required 15-minute safety checks. Staff interviews indicated that the single NA on duty was unable to complete more than one round of care for each resident due to insufficient staffing.