Delayed Medications Due to Nurses Arriving Late and Units Left Without Assigned Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff were present in the facility as assigned on their schedules, resulting in delayed medications and treatments for multiple cognitively intact residents. Several residents with complex medical conditions, including diabetes mellitus, chronic diastolic heart failure, hypertension, HIV, bipolar disorder, and other comorbidities, reported that nurses were not present on their units at the start of night shift or arrived late. Resident council minutes documented that residents stated there were no nurses on a couple of night shifts, and a concern form identified that a nurse not coming on time caused one resident to receive medications late. Residents serving as council president and vice president reported that there had been occasions when only one nurse was running all three floors and that nurses sometimes came in late. One resident, who is diabetic and on long-term insulin, stated he had received his insulin late on several occasions in the past, prompting him to raise concerns because the issue was happening often. Another resident reported that on multiple night shifts he came to the nursing station and found no nurse available; on one specific night around 11:30 PM he was told he would have to wait for pain medication because the night nurse had not yet arrived, and he had to go to another floor to obtain assistance from a different nurse. A registered nurse confirmed that on a night shift around 11:40 PM, a resident from another floor came to her unit stating there was no nurse on his unit and that he needed pain medication; she went upstairs, administered the medication, and noted that the assigned nurse for that unit arrived close to midnight. The administrator acknowledged being made aware of concerns about nurses running late and noted a trend of nurses arriving up to less than an hour late. The DON stated that residents had brought forward concerns that staff were coming in late and not notifying nursing leadership, and that it was an expectation that another nurse cover a unit when the assigned nurse was not present. The administrator also stated that the facility did not have a staffing policy and instead ensured only that minimum staffing ratios were met.
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