Failure to Correct Deficiency in Sufficient Nursing Staff
Penalty
Summary
The facility failed to correct previously identified deficiencies related to sufficient nursing staff, as evidenced by repeated concerns noted in both the current and past surveys. The QAPI program, revised in March 2020, is overseen by the QAPI committee and ultimately the Administrator, who is responsible for interpreting findings to the governing body. Despite this structure, the facility did not address ongoing issues with call light response times, which were brought up by residents during surveyor interviews but not reported to staff. The Administrator acknowledged that residents communicated their concerns about call lights to surveyors rather than staff, and that staff did not perceive or report these issues themselves. The Administrator indicated that call light audits had been conducted within the last year, but deficiencies related to staffing persisted, primarily based on resident interviews rather than direct observation. The Administrator also expressed the belief that staff would never feel they had enough help, and that increased staffing did not necessarily improve efficiency or outcomes. These statements and the lack of effective corrective action contributed to the facility's failure to resolve the deficiency regarding sufficient nursing staff.