Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from residents and staff, as well as a review of staffing schedules. Two cognitively intact residents with significant care needs, including assistance with toileting due to weakness, unsteadiness, and a history of falls, reported frequent delays in staff response to call lights, resulting in incontinent episodes while waiting for assistance. Both residents' care plans required staff support for toileting, with one requiring assistance every two hours or sooner upon request. Staff interviews corroborated these concerns, with CNAs and other personnel stating that there were not always enough staff to meet residents' needs in a timely manner. It was reported that call lights were not answered promptly and that non-certified staff, such as housekeepers, were sometimes assigned to monitor residents on the Alzheimer's unit due to staffing shortages. These non-certified staff members indicated they were not trained to provide care or handle resident behaviors and only performed basic monitoring while completing their regular duties. A review of staffing schedules and facility assessment tools revealed discrepancies between scheduled and actual staffing levels, with documented instances of only one or two CNAs present during certain shifts, despite the facility's own assessment indicating a need for more staff. The Director of Nursing and the Administrator both acknowledged that the number of CNAs on duty was insufficient to provide timely care, particularly on nights and weekends, and that staffing records were not always accurate.