Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being of ten out of eighteen residents. Observations and interviews revealed that call lights were not being answered promptly, with some residents experiencing delays of up to an hour. During an observation, six nursing staff members were seen seated at the nursing station without responding to a call light until a surveyor noted the time, prompting a response from a nurse aide. Residents reported long wait times for assistance, with some stating that there were not enough aides available, and those present were often on breaks. Grievances filed on behalf of residents highlighted issues such as inadequate staffing, resulting in residents not being moved, changed, or cared for in a timely manner. One grievance noted that a resident was not put to bed until late at night and had not been attended to since early morning. Another grievance mentioned a resident being told to wait until the next shift for assistance. Resident Council concerns also indicated ongoing issues with call light response times, particularly during the 3-11 shift and on weekends. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain sufficient nursing staff to meet residents' needs.
Plan Of Correction
Facility failed to have sufficient nursing staff to provide nursing and related services. Residents voiced concerns during the group interview regarding delayed call bell response times, inconsistent medication administration, and missed care (showers, shaving, etc.) due to insufficient staffing. Immediately following the survey exit on 3/28/25, the facility initiated the following corrective actions: Reassessment of current staffing levels and assignment adjustments were completed to prioritize resident care needs, including call bell responsiveness, medication administration, and resident hygiene. Nursing leadership provided direct support to ensure critical resident care needs were met. Nursing assistants were reallocated to high-acuity areas as needed to ensure residents received care timely. All residents in the facility have the potential to be affected by insufficient staffing. A comprehensive review of staffing levels and resident care delivery for all residents was conducted by the Director of Nursing (DON) and Nursing Home Administrator (NHA) by 4/5/25. Focus areas included: - Timeliness of call bell responses. - Medication administration times. - Resident care delivery (showers, shaving, repositioning, ambulation, etc.). Corrective actions were implemented immediately for any identified concerns, and resident care plans were updated accordingly. All nursing staff received education on 4/7/25 and 4/8/25 regarding: - Prioritizing resident care needs. - Timely response to call bells. - Importance of accurate documentation of care provided. - Facility policies on safe staffing and reporting staffing concerns. Staffing Review Process: The DON or designee will review staffing levels daily during the clinical morning meeting to assess: - Adequacy of staffing for all shifts. - Appropriate staff assignment based on resident needs. - Coverage plans for any call-offs. Weekend staffing coverage will be reviewed and confirmed by the Administrator or DON by the preceding Friday afternoon each week. The DON or designee will conduct random audits on all shifts, observing: - Call bell response times. - Medication administration timeliness. - Completion of showers and daily care tasks. Audits will be conducted 5 times per week for 4 weeks, then weekly for 2 months, and monthly for 3 months thereafter.