Inadequate Staffing on Dementia Care Unit
Penalty
Summary
The facility failed to provide adequate nursing staff on the Dementia Care Unit, which affected all 25 residents living on that unit. The Director of Nursing (DON) confirmed that the standard staffing pattern was one nurse and two CNAs per shift, but acknowledged that this was not always achieved due to CNA call-ins. Staff interviews revealed that the unit was often staffed with only one nurse and one or two CNAs, which was insufficient given the residents' high level of care needs, including incontinence, mechanical lift transfers, total feeding assistance, and behavioral supervision. Staff also reported that requests for increased staffing were denied by corporate administration. Family and staff interviews further documented the impact of inadequate staffing, including difficulty finding staff to assist with resident care and supervision, and instances where family members were called to help manage resident behaviors. Assignment sheets confirmed that on multiple occasions, only one CNA and a shared nurse were present on the Dementia Unit during overnight shifts. The facility's own staffing policy required adequate staffing to meet resident needs and regulatory requirements, but documented staffing levels did not consistently meet these standards.