Failure to Maintain Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and staffing records. Residents reported frequent delays in receiving care, including assistance with incontinence, showers, and bed baths, often waiting extended periods for help. Some residents described being left unattended for long periods, having their call lights turned off without receiving assistance, and feeling degraded when staff refused to help. Staff interviews confirmed that they were unable to consistently provide necessary care due to chronic understaffing, and that these issues were regularly reported to administration. A review of the facility's staffing schedules over several weeks showed that the number of licensed nurses and certified nurse aides on duty frequently fell below the minimum levels established in the facility's own assessment. On numerous occasions, both day and night shifts were staffed with fewer personnel than required, impacting the ability to provide timely and adequate care. The facility's staffing plan called for specific numbers of licensed nurses and aides per shift, but actual staffing often did not meet these targets. Leadership turnover was identified as a contributing factor to the staffing challenges, with the facility ombudsman and staff noting that inconsistent administration had exacerbated the problem. Despite attempts to fill staffing gaps through incentives, the facility was unable to maintain adequate staffing levels, resulting in unmet resident needs and compromised care. Staff competency and training were described as ongoing, but the primary issue remained the insufficient number of staff available to deliver care as required.