Failure to Provide Sufficient Nursing Staff on Evening Shift
Penalty
Summary
The facility failed to provide a sufficient number of nursing personnel on a 24-hour basis to meet the needs of all residents, as required by resident care plans, for one out of four days reviewed. On the afternoon and evening shift of 04/07/25, there were no certified nursing assistants (CNAs) available for approximately five hours, from 5PM to 10PM. This was confirmed by staff interviews and punch detail reports, which showed all scheduled CNAs had clocked out by 5:06PM, leaving only licensed nurses to provide care for the remainder of the shift. During this period, residents experienced delays in care. One resident reported that her call light was not answered when she needed assistance transferring from her wheelchair to bed, resulting in her transferring herself without staff supervision. Another resident, who typically went to bed at 7PM, was not assisted to bed until 10 or 11PM. Additionally, a resident's roommate had to change her brief because her call light was not answered and staff did not respond to her needs. Interviews with staff confirmed that nurses had to perform all CNA duties, including answering call lights, feeding, and providing incontinence care, in addition to their regular nursing responsibilities. The facility's own assessment tool indicated that a minimum of two CNAs were needed for the afternoon shift, and the facility's policy required that licensed nurses and CNAs be available 24 hours a day to provide direct resident care. However, on the day in question, there was a failure to ensure adequate CNA coverage, resulting in unmet care needs and delays in assistance for multiple residents.