Failure to Provide Adequate Staffing Resulting in Missed Care and Delayed Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, record reviews, and staffing schedules. Certified Nursing Assistants (CNAs) reported that staffing levels were frequently below the facility's recommended numbers, particularly on the Liberty Lane unit, which has a high number of residents requiring heavy care and mechanical lifts. Staff described situations where only two CNAs were available for 27 residents, making it difficult to provide timely care, including showers, toileting, and feeding assistance. Staff also reported that when short-staffed, they had to prioritize care, resulting in missed or delayed showers and incontinence care, and longer wait times for call lights to be answered. Residents corroborated these accounts, with one resident documenting long periods between being checked or changed and waiting over 30 minutes for call lights to be answered. This resident also reported missing scheduled showers and feeling dismissed by staff when raising concerns. Another resident stated that it was common to wait 40-45 minutes for call lights to be answered and was told that showers could not be provided due to insufficient staffing. Review of shower sheets confirmed that some residents did not receive the facility's policy of two showers per week, and there were days with no documentation of showers or bed baths for certain residents. The facility's staffing schedules and logs showed multiple days within a two-week period where the number of CNAs on duty did not meet the facility's own recommended levels. On one such day, a resident with a history of falls was left unsupervised and experienced a fall resulting in a hospital visit. Staff and the Director of Nursing acknowledged ongoing staffing challenges, especially during call-ins, and confirmed that these shortages impacted the ability to provide timely and complete care to residents, including supervision, showers, and incontinence care.