Insufficient Staffing During Shift Change Leads to Unanswered Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs during a shift change on three of six resident halls. During the transition from day to evening shift, only one CNA was present on the floor while three nurses remained at the nurse's station, and five resident call lights were observed activated for approximately 30 minutes without response. Multiple staff interviews confirmed that CNAs left the floor without notifying nurses, and one CNA had been sent home on administrative leave, further reducing available staff. Nurses at the station were unaware that the CNAs had left and did not respond to the call lights, resulting in residents' needs going unmet for an extended period. A resident was heard calling for help, stating her call light had been on for 30 to 40 minutes and she needed assistance. Staff interviews revealed that it was common for CNAs to leave the floor before the next shift arrived and that walking rounds were not conducted to communicate care needs to the oncoming shift. The Assistant Director of Nursing and other nursing staff were unaware of the absence of CNAs during this period, and administrative staff confirmed ongoing staffing shortages and efforts to recruit additional staff. The facility's staffing policy requires adequate staffing based on resident acuity and needs, but this was not maintained during the observed shift change.