F0725

K

Insufficient Nursing Staff Leading to Unsafe Transfers, Falls, and Delayed Incontinence Care

Merkel, Texas Survey Completed on 02-16-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skill sets to meet resident needs on 34 of 84 reviewed shifts, despite a facility assessment requiring at least two direct care staff and one nurse per shift. Timecard review showed that on multiple specified dates and shifts between early January and early February, only one direct care staff member was on duty, even though the facility had residents requiring mechanical lifts and two-person transfers. Interviews with leadership acknowledged that the facility was short staffed due to staff quitting, difficulty hiring in a rural area, and inability to compete with larger facilities and hospitals, and that resident care suffered because of being short staffed.

One resident with a left femur fracture, severe cognitive impairment (BIMS score 00), and a care plan requiring two-person maximum assistance and two-person mechanical lift transfers was inappropriately transferred by a single NA without a mechanical lift. The NA reported she was the only aide working, knew the resident required a mechanical lift and two staff, but transferred him alone because no help was available and stated she routinely transferred him this way. Another resident with heart failure, kidney disease, severe cognitive impairment (BIMS score 07), and a care plan identifying high fall risk and the need for prompt response to call lights fell after using the call light for toileting assistance, waiting, then attempting to go to the restroom alone. Her call light was observed activated with no staff present in the hall or at the nurses’ station; she reported she always had to wait a while for staff to answer her call light and that she had fallen before. Timecards showed only one direct care staff was on shift at the time of this fall.

A third resident with colon cancer, muscle weakness, and moderate cognitive impairment (BIMS score 09), who used a walker and wheelchair and required one-person assistance for transfers, had multiple falls over a short period, including two falls on the same day that led to hospitalization for rib fractures and pleural effusion. Progress notes described falls occurring while the resident attempted to get on the commode and when she was found on the floor between the bathroom and her room, with documentation of weakness and difficulty standing. The incident log showed numerous falls, and the care plan identified high fall risk related to weakness, but there were no updates to fall interventions since several months prior. Timecards indicated only one direct care staff was on duty during the falls that occurred that day. Another resident with depression, anxiety, severe cognitive impairment (BIMS score 01), partial/moderate assistance needs for transfers, and occasional incontinence waited approximately two hours to be changed after an incontinent episode. She was repeatedly told by the only aide on shift that the aide was too busy, was observed crying and still unchanged in the hall and dining room, and later had her request to an RN ignored before finally being changed about two hours after her initial request. The aide stated she had been working alone more often since other staff had quit, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting needed care and could be considered neglect.

Leadership interviews further linked these events to insufficient staffing. The AIT confirmed that on one of the key days only one aide was working because another did not show up, and acknowledged that it was not safe to have only one NA on the floor and that a resident should not have been transferred without a mechanical lift. The AIT stated her expectation was that residents be taken care of by whatever means necessary, while also acknowledging that policies and procedures were not always realistically followed. The ADON reported that the facility had been short staffed due to staff not wanting to work, staff quitting, and hiring challenges, and stated that resident care suffers because of being short staffed. The MD stated he was not aware the facility had been using so many uncertified aides and that the facility should have been using agency staff to ensure residents received care from qualified staff. These observations, interviews, and record reviews formed the basis for the Immediate Jeopardy determination related to insufficient nursing staff and resulting resident care failures.

Removal Plan

• Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA training employed less than 120 days, CNA, LVN, or RN providing direct care).
• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; maintain a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents.
• Assess staffing requirements weekly based on census and resident needs; ensure two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure all agency or temporary direct care staff have documented training prior to working a shift by checking credentials via the agency portal and obtaining sister-facility CNA credentials prior to shifts.
• Require two direct care nursing staff on each rotation.
• Utilize staffing agency and aides from the sister facility if the facility does not have enough qualified staff.
• Complete the facility assessment weekly to assess acuity and needs for direct care nursing staffing requirements.
• IDT will review the facility assessment policy for guidance on acuity levels and staffing needs.
• Follow the facility assessment to determine staffing needs.
• Assess Residents #5, #3, #2, and #16 for any further injury, emotional distress, or pain.
• Conduct an immediate review of staffing patterns to evaluate gaps in coverage and staffing needs.
• Contact temporary staffing agencies to meet staffing requirements.
• Use aides from the sister facility to cover staffing gaps until staffing agency assignments are filled.
• Implement temporary agency staffing to ensure two direct care staffing coverage.
• Request a copy of aide certification from the staffing agency.
• Conduct certification checks on all aides arriving from the sister facility.
• Charge nurse will verbally educate any agency and sister-facility staff during shift report (before starting) on call lights, mechanical lift, and abuse/neglect.
• Charge nurse will require verbal return instruction from agency/sister-facility staff before they start the shift to determine competency.
• Adjust the schedule to prevent only one direct care staff at any time, using temp agencies and sister-facility CNAs.