Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of its resident population, as evidenced by multiple resident and staff interviews, observations, and documentation review. Residents reported extended wait times for assistance, with some call lights going unanswered for up to 40-45 minutes or longer, particularly during night shifts and weekends. One cognitively intact resident described waiting over 40 minutes to be changed, despite repeated requests and staff being present in the hallway. Another resident reported waiting up to two hours for assistance with basic needs such as water or catheterization, and noted that staff often cited understaffing as the reason for delays. Additional residents described similar experiences, including missed or delayed assistance with activities of daily living (ADLs) such as bathing, with documentation confirming multiple missed scheduled bed baths and showers over a 90-day period. Family members also observed issues, such as strong urine odors and soiled briefs left in rooms, indicating delays in incontinence care. During a resident council meeting, concerns were raised about frequent staffing shortages, with reports of only one staff member per hall and wait times for call lights ranging from one to three hours. Staff interviews corroborated these findings, with nurse aides acknowledging frequent call-ins, difficulty covering shifts, and the resulting impact on resident care. Observations during the survey showed multiple call lights going unanswered while some staff were not actively responding to resident needs. The Director of Nursing confirmed gaps in care documentation, and no additional evidence was provided to refute the reported deficiencies.