Failure to Provide Sufficient Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and oversight to meet the needs of all residents, resulting in multiple instances where residents did not receive timely care and assistance. Observations and interviews revealed that several residents, including those with significant mobility limitations, incontinence, and other complex medical conditions, experienced prolonged wait times for assistance with toileting, repositioning, and other activities of daily living (ADLs). For example, one resident with morbid obesity and reduced mobility waited over an hour to be assisted onto a bedpan, despite repeated requests and calls for help. Another resident reported being left in a wet pad for over two hours, with staff failing to respond to call lights in a timely manner. Call light response logs and resident interviews indicated a pattern of delayed responses, with numerous instances of call lights going unanswered for 20 minutes or more, and in some cases, up to several hours. Residents and staff reported that agency nursing assistants were often observed using cell phones while on duty, and there was a lack of accountability and supervision to ensure prompt response to resident needs. The facility's own policy required call lights to be answered within five minutes, but this standard was not met, as evidenced by both documented response times and resident grievances. Further review showed that the facility did not provide adequate orientation, training, or supervision for agency nursing assistants, and failed to ensure comprehensive care planning for residents with incontinence. The Director of Nursing and Assistant Director of Nursing acknowledged awareness of delayed call light responses but did not consistently review or act upon call light response data. The lack of effective communication and coordination among staff, as well as insufficient staffing levels and oversight, contributed to residents not receiving timely and appropriate care.