Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by clinical record reviews, PBJ data, and multiple staff and resident interviews. One resident with intact cognition reported that call light response times could take 30 to 45 minutes or longer, and that staff sometimes turned off the call light without returning. Facility records and resident council documentation confirmed call light response times between 15 and 30 minutes. PBJ data reflected excessively low staffing on weekends, and staff interviews described frequent situations where only one nurse and one CNA were responsible for nearly 40 residents. Staff also reported that management did not assist with direct care during shortages, and that staff were often required to find their own replacements when calling in absent. Staff described being mentally and physically exhausted due to chronic understaffing, particularly during evening and weekend shifts. They reported difficulty completing essential care tasks, such as resident baths, and managing increased resident needs during high-activity periods like bedtime. The DON acknowledged that the facility's policy expected call lights to be answered within 15 minutes, but described ongoing challenges in maintaining adequate staffing levels, especially after hours and on weekends. The facility's own grievance documentation and staff interviews consistently indicated that staffing levels were insufficient to provide timely care to all residents.