Failure to Provide Sufficient Staffing and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 106 residents, including not ensuring a licensed nurse was present on each unit during every shift. On multiple occasions, staffing records and interviews confirmed that only two CNAs were scheduled for shifts where five residents required one-to-one supervision as part of their care plans. These residents had complex medical and behavioral needs, such as dementia with agitation, physical aggression, wandering, and inappropriate behaviors, yet did not consistently receive the required supervision. Staff assignment sheets and behavior monitoring documentation showed that one-to-one supervision was not provided as required, particularly during night shifts, and staff reported it was impossible to meet these needs with the available personnel. Observations during the survey revealed that staff were sometimes assigned to supervise more than one resident at a time, and at other times, residents who required one-to-one supervision were left without any assigned staff. Interviews with CNAs and the staffing coordinator confirmed ongoing staffing shortages, with staff unable to complete required monitoring and documentation. The Director of Nursing acknowledged the absence of a formal staffing policy or a policy for one-to-one supervision, and that nursing judgment was used to determine supervision needs without physician orders or defined timeframes. Additional findings included reports from residents about delays in receiving assistance, with some stating they had to wait for help or were told they could not return to bed due to insufficient staff. The Social Services Director indicated that staffing shortages prevented all required interdisciplinary team members from attending care conferences. Staff also reported being asked to cover multiple units, which they felt was unsafe and put their professional licenses at risk. The administrator confirmed multiple open CNA, LPN, and RN positions and the lack of a staffing policy.