Failure to Provide Adequate Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents reported that there were not enough staff, particularly aides, resulting in long wait times for assistance and unanswered call lights. Staff interviews corroborated these concerns, with both CNAs and LPNs stating that staffing levels were insufficient to manage the census and acuity of the residents, especially in units with higher care needs. Specific incidents highlighted the impact of inadequate staffing on resident care. One resident with chronic respiratory failure, diabetes, and impaired mobility was observed calling out for help and unable to reach her call light, which was found out of her reach. The assigned CNA had left, and there was no coverage, leaving the resident without assistance. Another resident with impaired mobility and requiring a mechanical lift reported not being able to get out of bed at her preferred time due to staff shortages. A third resident, who required maximum assistance for ADLs, remained in bed throughout the day despite repeated requests for help, as confirmed by both the resident and a CNA. These findings were based on direct observations, interviews, and review of care plans and MDS assessments, demonstrating that the facility did not ensure sufficient staffing to meet residents' needs for timely assistance with activities of daily living, mobility, and safety. The deficiency was identified during the investigation of multiple complaints and had the potential to affect all residents in the facility.