Insufficient Nursing Staff Resulting in Prolonged Resident Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in prolonged wait times for assistance with activities of daily living and incontinence care. Multiple residents and family members reported excessive delays after activating call bells, with documented instances of call bells going unanswered for over 30 minutes, and in some cases, up to 117 minutes. Call bell logs from October 2024 to January 2025 showed a significant number of alarms with delayed responses. One resident was documented to have waited over an hour for incontinence care, during which time the resident was observed crying and expressing distress. Resident Council attendees also reported that the night shift was particularly understaffed, with only two Certified Nurse Aides assigned to care for 40 residents, leading to delays in receiving necessary care such as transfers and incontinence assistance. Staff interviews confirmed that staffing levels were often insufficient, especially during the night shift, and that nurses sometimes assisted with care but did not alleviate the heavy workload of the aides. Residents reported being told to urinate in their briefs due to the lack of timely assistance. The Director of Nursing acknowledged that a wait time exceeding 20-25 minutes was unreasonable, yet audit data and resident reports indicated that such delays were frequent. Family members also expressed concern about the time it took for staff to respond to call bells, noting that staff would often leave to find a second person and not return for extended periods.