Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to ensure adequate nursing staff were scheduled to meet the needs of all residents on the third floor, which housed 36 residents. On multiple occasions, only two CNAs were assigned to care for all residents on the unit, despite the facility's stated goal of three CNAs per shift. Staff interviews confirmed that CNAs were sometimes pulled from the third floor to cover shortages elsewhere, resulting in insufficient staffing. Observations revealed that incontinence care was delayed, with several residents found in saturated briefs during the morning, and some residents remained in bed past breakfast time due to lack of available staff. Staff, including CNAs and an LPN, reported difficulty completing all required tasks such as showers, toileting, and getting residents up for meals when staffing was below the intended level. The staffing scheduler and unit manager acknowledged that the unit sometimes operated with only two CNAs when call-offs occurred and replacements could not be found. Review of staffing schedules showed multiple shifts with only one or two CNAs assigned, and on one date, no CNA was listed for the third floor. Resident and family interviews, as well as resident council meeting minutes, documented ongoing concerns about delayed call light responses, unmade beds, and inconsistent provision of basic care such as passing ice water. Residents reported waiting one to two hours for call lights to be answered and noted that staff sometimes turned off call lights without addressing their needs. These issues were repeatedly raised in resident council meetings over several months, indicating a persistent problem with inadequate staffing and unmet resident needs.