Failure to Provide Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports of delayed response to call lights, missed or delayed care, and medication administration outside of scheduled times. Several residents with significant medical needs, including hemiplegia, diabetes, heart failure, cognitive impairment, and recent surgery, reported waiting 30 minutes to over an hour for assistance with toileting and other personal care. Some residents experienced incontinence while waiting for help, leading to feelings of humiliation and frustration. One resident resorted to emptying his own urinal due to lack of timely staff response, and another's spouse reported frequent delays resulting in accidents. Resident council meeting minutes over several months documented ongoing concerns about inadequate staffing, long call light wait times, missed showers, and staff turning off call lights before providing assistance. Residents consistently expressed that there were not enough CNAs to meet their care needs, and staff confirmed that frequent call-offs and reduced nurse staffing contributed to the inability to complete required tasks, such as providing showers and timely assistance. Staff also reported that high-acuity residents often required two-person assistance, further straining available resources. Medication administration was also affected by staffing shortages, with documentation showing that medications were given significantly outside of scheduled times. A physician noted poor communication and frequent staff turnover, stating that patients were not receiving appropriate care and that it was difficult to reach facility leadership. The DON acknowledged ongoing complaints about call light response times and attributed the issue to staffing cuts and changes in facility management structure. Facility policies required prompt response to call lights and timely medication administration, but these standards were not met.