Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents, as evidenced by multiple instances where residents' requests for assistance were not met in a timely manner. One resident, who was totally dependent on staff for bed mobility, toileting, dressing, and transfers due to hemiplegia, hemiparesis, and moderate cognitive impairment, reported that he had asked several staff members to help him get out of bed after breakfast but remained unattended for several hours. Despite activating his call light and repeated requests, he was not assisted until much later in the day, and his call light was turned off by staff and administration without his needs being met. The resident expressed concern that his requests were not being addressed and that staff were not responsive to his needs. Another resident was observed with her call light on, requesting pain medication and a brief change. While she received her pain medication, her request for a brief change was not addressed for an extended period, and she reported not seeing her assigned CNA since the morning. The call light remained on for over an hour before her needs were met, and she refused her lunch tray until she was cleaned up. Staff interviews confirmed that call lights should remain on until resident needs are met, but this protocol was not consistently followed. A review of facility records and interviews with staff revealed ongoing staffing issues, particularly on weekends, with the facility experiencing low staffing levels on approximately three days each week. Payroll records confirmed excessively low weekend staffing and a one-star rating. The facility's staffing coordinator and administration acknowledged these issues, and the facility's assessment tools indicated a high number of residents with behavioral health needs and high acuity, further emphasizing the need for adequate staffing to meet resident care requirements.