Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to meet the needs of three residents, as evidenced by multiple delays in care and unmet resident needs. Resident 5, who was cognitively intact and required assistance with personal hygiene and dressing, reported waiting up to an hour for staff to assist with her nasal cannula for oxygen, both at night and during the day. Resident 6, who was severely cognitively impaired, legally blind, and required substantial assistance with toileting, stated she often waited an hour or more for staff to change her incontinence pad, and had developed a sore on her bottom. Resident 41, who was moderately cognitively impaired and required maximal assistance with bathing and toileting, was observed calling for help from her bed and reported waiting up to two hours for restroom assistance. Staff interviews revealed that CNAs did not consistently follow facility policy regarding the endorsement of resident care when leaving their assigned areas for breaks or lunch. One CNA admitted to not informing another CNA upon returning from lunch, resulting in a lack of coverage for assigned residents. Other CNAs confirmed that the policy required them to endorse care to another CNA when leaving the unit, but this was not always practiced. The DON stated that all staff, including housekeeping, were trained to answer call lights and that call lights should be answered within ten minutes, but observations and resident reports indicated this standard was not consistently met. Resident council feedback and direct resident interviews further corroborated the staffing issues, with residents reporting frequent and prolonged waits for assistance. Facility policies reviewed indicated a requirement for sufficient and competent nursing staff and prompt response to call lights, but these procedures were not consistently followed, resulting in unmet care needs for multiple residents.
Plan Of Correction
CORRECTIVE ACTION On 3/6/2025, staff answered the call lights timely. On 3/21/25, staff were provided in-service by the DON regarding the importance of answering call lights timely and the importance of endorsing resident care before going on breaks and/or leaving for the day. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/24/25, the SSD interviewed 7 alert residents to ask if the call lights are being answered timely. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES During the shift huddle, staff will be reminded to answer call lights promptly and to endorse resident care before going on breaks and/or leaving for the day by the RN supervisor/designee. DON/designee will interview 5 random residents weekly to check if their lights are being answered timely. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.