Failure to Provide Adequate Nursing Staff Results in Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide the minimum required nursing staff to meet the needs of all 248 residents, resulting in unmet care needs and delays in assistance. Payroll Based Journal records indicated excessively low weekend staffing, particularly during holidays and the months of January and February, with frequent staff call-offs due to sickness. Surveyor observations and resident interviews revealed long waits for assistance, delayed incontinence care, and late meal delivery. Residents reported waiting hours to be changed, experiencing pain management delays, and not having call lights answered for extended periods. Some residents described falling due to lack of staff assistance, including one who required two-person assistance for transfers and another who was not changed all night. Staff interviews confirmed that shortages were more pronounced on weekends and night shifts, with CNAs reporting increased workloads and reliance on registry staff, who were sometimes late or absent. The Staffing Coordinator and DON acknowledged that short-staffing led to increased resident complaints and delays in care. Facility policy required staffing levels to be based on resident needs, but the observed and reported staffing levels were insufficient to meet those needs, directly impacting resident care and well-being.