Inadequate Staffing Leads to Delayed Resident Care and Unanswered Call Lights
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by consistent understaffing on both day and night shifts. Staffing assignment sheets showed that although extra CNAs were scheduled, they were routinely sent home if the state minimum staffing was met, leaving only six CNAs on day shift and four on night shift for a census of 72 to 76 residents. Staff, residents, and family members reported frequent delays in call light responses, with some residents waiting up to an hour or more for assistance with incontinence care, transfers, or other needs. Multiple grievances were filed regarding slow response times, and direct observations by surveyors confirmed call lights going unanswered for extended periods, including one instance where a resident's call light was not answered for 21 minutes until the surveyor intervened. Several residents required high levels of care, including 31 out of 72 residents needing full mechanical lifts for transfers, which require two CNAs to operate safely. Staff interviews revealed that the reduction in CNA staffing made it difficult to provide timely care, complete showers, and respond to call lights, especially on halls with residents requiring more intensive assistance. The facility's own assessment acknowledged the need for sufficient nursing staff with appropriate competencies to ensure resident safety and well-being, but staffing decisions were based solely on meeting state minimum requirements rather than the actual acuity and needs of the resident population. Specific incidents included a resident who waited over an hour to be changed after incontinence, another who attempted to transfer herself after waiting too long for help and subsequently fell, and multiple reports from residents and family members about long waits and unmet care needs. The Director of Nursing and other staff confirmed that staffing was determined by census and state minimums, despite the heavy care needs of many residents. The facility's grievance log, staff, and resident interviews, as well as direct observations, all supported the finding that inadequate staffing led to delays in care and unmet resident needs.