Failure to Maintain Minimum Nurse Aide Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide the minimum required number of nurse aides on each shift as outlined in its own facility assessment, which specified a minimum of three nurse aides per shift. Staffing records revealed that on several occasions, including the entire month of May and into June, only two nurse aides were scheduled and present on night shifts, and on at least one day shift, there were no nurse aides present. This staffing shortfall resulted in prolonged call light response times, with multiple documented instances of call lights remaining unanswered for over 30 minutes, and in some cases, exceeding an hour. Observations and interviews confirmed that call lights were not answered within the facility's expected timeframe of 5-15 minutes, and staff acknowledged that the lack of adequate staffing contributed to these delays. Additionally, the insufficient staffing impacted resident care, as evidenced by a resident who did not receive weekly baths as preferred and required, with documentation and interviews confirming that the resident had not been bathed for at least a month. The resident also had a wound on the leg and was informed by staff that bathing would help, but the lack of available staff prevented this care from being provided. Staff interviews further corroborated that baths were not being completed regularly due to staffing shortages. The Director of Nursing confirmed that the facility did not track call light response times or have action plans to address the delays, and both the Administrator and DON acknowledged that the staffing levels and response times were not acceptable.