Failure to Maintain Sufficient and Responsive Nursing Staff
Penalty
Summary
On July 23, 2025, observations on the B Wing nursing unit revealed that five resident call bells were illuminated and audibly ringing, indicating that residents were seeking assistance. At the same time, lunch carts had been delivered to the hallway but the trays had not been distributed to the residents. Four employees were observed gathered in a side room with the door closed, and a licensed employee was seen sleeping in front of the computer at the nurses' station. These conditions persisted for approximately 15 minutes, during which the resident call bells remained unanswered and the lunch trays were not delivered. The findings were communicated to the Nursing Home Administrator and Director of Nursing. The report cites a failure to ensure adequate and competent staffing levels to promptly respond to resident needs, as required by federal and state regulations.
Plan Of Correction
1. Licensed nurse was educated on sleeping and received disciplinary action for sleeping. Nursing staff on B wing were educated on timely tray pass and call light response time. 2. Call response times have been reviewed with resident council members to ensure timely response. 3. Education will be completed by the DON/designee with all direct care staff and interdisciplinary team related to call light response, congregating at nurses' station, sleeping, and meal tray delivery. 4. The DON/designee will review call bell response times, sleeping, congregating at nurses' station, and meal tray delivery three days per week for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.