Insufficient Nursing Staff Resulting in Missed Care and Delayed Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several instances where care was not delivered as required. On one occasion, a certified nursing assistant (CNA) reported being the only CNA on a unit with eight residents requiring two-person assistance with mechanical lifts, leading to four residents remaining in bed due to lack of available staff. Additionally, staff were unable to round on residents during a night shift because a CNA was absent, as documented in the facility's schedule. Staff interviews confirmed that concerns about inadequate staffing had been communicated to facility leadership, but the issue persisted, particularly on units with higher acuity residents. Surveyors also observed delays in meal service, with residents in the dining room receiving breakfast trays 1.5 hours after the scheduled time due to insufficient staff to pass trays and assist with feeding. The facility's staffing assessment and schedules indicated discrepancies between planned and actual staffing levels, with staff coordinators and leadership acknowledging challenges in maintaining adequate coverage, especially when call-ins occurred. The facility relied on agency nurses but not agency CNAs, and staff often had to be pulled from other units to cover shortages. Leadership interviews revealed uncertainty about how staffing levels in the facility assessment were determined, as the previous administrator was responsible for its creation.