Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the care needs of five residents, as evidenced by multiple instances of delayed response to call lights and inadequate assistance with toileting hygiene. The facility's policy on answering call lights, which requires staff to promptly respond to residents' requests and provide necessary assistance, was not adhered to. This resulted in residents being left in soiled conditions for extended periods, ranging from half an hour to several hours. Resident R1 reported being left in a soiled brief from 6 p.m. to 2 a.m. over a weekend, despite using the call bell multiple times. Staff reportedly turned off the call light without providing assistance, indicating they would return later. Similarly, Resident R2 experienced delays in receiving help for toileting hygiene, with waits ranging from half an hour to two hours. Resident R3, who has a broken hip and is dependent on staff for toileting, reported waiting up to three and a half hours for assistance, with staff citing breaks as a reason for the delay. Resident R4, who requires substantial assistance for toileting, also experienced delays, having to wait over an hour on occasion. Resident R5 reported similar issues, with waits exceeding half an hour. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to provide sufficient staffing to meet the residents' needs, impacting the quality of care for these individuals.
Plan Of Correction
F 0725 Sufficient Nursing Staff The facility failed to ensure sufficient staffing to meet residents' care needs for five of fifteen residents who require care (Residents R1, R2, R3, R4 and R5). What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Social Services met with residents R1, R2, R3, R4 and R5 to discuss the identified situation and ensure all care needs were met in a timely manner. Daily staffing meetings will be held with scheduler, DON and Admin and/or designee to ensure sufficient staffing is provided for all 3 shifts and meeting the staffing ratio and PPD. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The staff educator provided education to all staff on prompt response for "Answering call Lights." Daily Huddles will occur with administrative staff and/or designee with all floor staff to communicate necessary needs expressed by residents during guardian rounds. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? Daily Huddles will be initiated to ensure all staff is informed of residents' needs and staffing will be reviewed as well as assignments given to ensure all residents receive timely care. The DON and/or designee will complete an audit 2x a week with 5 residents for two weeks to ensure all residents have received prompt care and in a timely manner, as well as complete staffing tool to ensure facility is meeting ratio and PPD. How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? All audit findings will be reviewed by DON and/or designee at the monthly Quality Assurance Meeting to determine if deficient practice has been corrected or will need to continue by DON and/or designee. Dates of when the corrective action will be completed: April 24th, 2025.