Failure to Maintain Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident and staff interviews, review of complaints, and staffing records. Several residents reported long delays in response to call lights, inconsistent medication administration times, and lack of assistance with basic needs such as feeding and hydration. One resident described waiting over an hour for help after activating the call bell at night, while another noted that agency staff appeared disengaged. Residents consistently expressed concerns about inadequate staffing, particularly during evening and night shifts. Staff interviews corroborated these concerns, with GNAs reporting that they were sometimes the only aide on a unit responsible for over 30 residents, leading to incomplete care tasks such as changing pads and repositioning residents. Staffing records confirmed that on multiple occasions, night shifts were staffed with only one GNA per unit, despite resident censuses ranging from 29 to 63. The DON acknowledged the staffing issues raised by both residents and staff. These findings demonstrate a pattern of insufficient staffing that directly impacted the timeliness and quality of care provided to residents.