Insufficient Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by observations and interviews with residents and staff. On February 4, 2025, a call bell light in room 304 was observed to be on for over 30 minutes without being answered, indicating a delay in response time. Resident R180 reported that delayed call bell responses were common and attributed this to nurse aides leaving or being reassigned to other units. Multiple residents expressed concerns about the lack of nurse aides, which affected their care, including shower schedules and timely assistance. A nursing aide, Employee E16, reported feeling overwhelmed with a caseload of 13 residents and noted that only two aides were working during the day shift, which she felt was insufficient. Further interviews revealed that residents were concerned about the timeliness of call bell responses and medication administration due to inadequate staffing. During a resident council meeting, several residents reported that the biggest issue in the facility was the shortage of nursing aides and nurses, leading to long wait times for assistance and delayed medication administration. The lack of sufficient staff was also linked to an increase in falls, as residents attempted to use the bathroom without assistance. The facility's failure to provide adequate nursing staff was in violation of regulatory requirements, as it did not ensure the safety and well-being of its residents.
Plan Of Correction
Residents R180, R46, R155, R247, R75, R78, R137, R32, R134, R11, R161 and R7 had no ill effects from this alleged deficient practice. The facility cannot retroactively correct this alleged deficient practice. Staff Development Nurse/designee educated the nursing staff on the call bell policy. Licensed staff were educated on medication administration policy with emphasis on timeliness. Facility department heads/designee will complete random call bell audits on units weekly x4 then monthly x2 and report findings to QAPI meeting monthly.