Inadequate Staffing Leads to Unmet Resident Needs and Delayed Care
Penalty
Summary
The facility failed to provide adequate direct care staffing hours to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. The facility's own Facility Assessment indicated an expected 196 CNA hours per 24-hour period, but on the reviewed date, only 116 CNA hours were provided for 75 residents. Resident council minutes documented ongoing concerns about unmade beds, unchanged sheets, and delayed call light responses. Multiple residents reported that their requests for assistance were not answered in a timely manner, with one resident stating she soiled herself after waiting for help with toileting for several hours. During meal times, residents requiring assistance with eating were observed left unattended in the dining room, with no staff present to provide necessary support. Two residents were seen with full plates of uneaten food, one of whom was sleeping at the table, and another who required encouragement and physical assistance to eat. Staff interviews confirmed that CNA coverage was insufficient, with one CNA stating she was the only aide on her hall and unable to keep up with resident needs, especially for those requiring two-person transfers or feeding assistance. Further interviews with staff, including a LPN and the scheduler, revealed that staffing shortages had worsened over the past month due to call-ins and unfilled shifts. The scheduler was unaware of state minimum staffing requirements and acknowledged that staff were experiencing burnout and unwilling to work extra shifts. The facility also lacked a DON and an Infection Control Preventionist at the time of the survey, further impacting the ability to ensure adequate staffing and supervision.