Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents for 24 out of 30 days reviewed, resulting in delays in care and unmet resident needs. Multiple residents reported waiting extended periods for assistance with activities of daily living, such as getting out of bed, dressing, and toileting. One resident, admitted for short-term rehabilitation following a back fracture, experienced incontinence while waiting for staff to respond to a call bell. Another resident reported waiting over an hour to be assisted back to bed, and the resident council expressed concerns about long call bell wait times, particularly on the 3-11 shift and weekends, when only one LNA was often responsible for up to 30 residents per unit. Staff interviews confirmed frequent short staffing, with LNAs and RNs regularly covering additional shifts and roles outside their primary responsibilities, including the Infection Preventionist missing key meetings due to covering direct care shifts. Staff members, including the Scheduling Coordinator, LNAs, RNs, and the Infection Preventionist, consistently reported ongoing short staffing, especially on evening shifts. The Director of Nurses confirmed that a significant number of residents required extensive assistance, including mechanical lifts and two-person assists, yet staffing levels were insufficient to meet these needs. Documentation from resident council meetings and interviews with residents and their representatives further corroborated the persistent issue of inadequate staffing, leading to delays in care and missed activities. The facility's matrix showed 14 new admissions in the past 30 days, further straining available staff resources.