Failure to Provide Adequate CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate Certified Nursing Assistant (CNA) staffing for eight out of fourteen days reviewed, as documented by daily staffing assignment sheets and confirmed by facility leadership. The facility assessment indicated a need for 16 CNAs per 24-hour period, but on multiple days, staffing fell below this requirement, with as few as 10 CNAs present on some days. This staffing shortage was acknowledged by the Regional Director of Operations and the scheduler, who noted ongoing difficulties in filling shifts and reliance on agency staff and flexible scheduling to cover gaps. Multiple residents, all documented as cognitively intact, reported significant delays in having their call lights answered, sometimes waiting up to an hour for assistance with basic needs such as transfers, toileting, and getting out of bed. One resident, who required two staff and a mechanical lift for transfers, waited over 30 minutes for help and was told to wait until the day shift arrived due to insufficient staff. Other residents described similar experiences, including long waits for assistance and unaddressed hygiene needs. Staff interviews corroborated these accounts, with an agency LPN stating that call lights were going unanswered and that she had to choose between providing resident care and completing medication passes due to the lack of available CNAs.