Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident complaints and documented staffing shortages. Several residents reported significant delays in receiving assistance with activities of daily living (ADLs) and in response to call lights, particularly during evening and night shifts. For example, one resident described waiting 15 to 20 minutes for help after sliding off his bed, with no staff responding even after his roommate also activated the call light. Other residents confirmed similar experiences, with some waiting over 30 minutes or even up to an hour for assistance, including for pain medication and toileting needs. These residents were cognitively intact and had medical conditions such as spinal fusion, cauda equina syndrome, kidney disorders, pulmonary issues, fractures, and mobility difficulties, all of which increased their need for timely care. A review of facility records revealed that the required minimum of 2.4 Certified Nursing Assistant (CNA) Direct Care Service Hours Per Patient Day (DHPPD) was not met on 16 days in March and 11 days in April. Staffing assignment sheets showed that the number of CNAs on duty frequently fell below the facility's own assessment projections, resulting in higher resident-to-CNA ratios than planned. On several occasions, three CNAs were responsible for up to 18 residents during night shifts, and day and evening shifts were also understaffed. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that these staffing levels were insufficient to provide safe, efficient, and adequate care, and that the required DHPPD was not consistently achieved. Facility policies required timely responses to call lights and sufficient staffing to meet resident needs as outlined in care plans and the facility assessment. Despite these policies, the documented staffing shortages and resident reports of delayed care demonstrate that the facility did not adhere to its own standards or regulatory requirements. The DSD and DON confirmed that the lack of adequate staffing led to delays in care, increased risk for falls, and residents being left soiled or without timely assistance.