Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by not following its own facility assessment staffing guidelines for 74 out of 87 shifts reviewed over a one-month period. The facility's assessment outlined specific staffing requirements per shift, including the number of RNs, LPNs, CNAs, and other support staff needed to care for residents with a wide range of diagnoses and care needs, such as psychiatric disorders, heart and circulatory conditions, neurological disorders, and residents requiring assistance with activities of daily living. Despite these guidelines, staffing records showed that many shifts were either partially or completely unstaffed according to the facility's own standards. Observations and interviews with staff revealed that the lack of adequate staffing led to delays in meeting residents' needs. CNAs reported that residents often had to wait a long time for assistance, and that beds were left unmade and rooms were messy, particularly on weekends. Dietary staff noted that residents complained about their food getting cold while waiting for help, and that food trays were sometimes returned untouched, possibly due to the absence of staff to assist residents to the dining room. Record reviews further indicated that the insufficient staffing contributed to care issues, including multiple resident falls, some resulting in major injury, and medication administration delays. For example, one resident with orders for both long-acting and fast-acting insulin received doses late on 16 occasions during the month, sometimes up to four hours past the scheduled time. The DON confirmed that the facility did not use temporary or contract staff and acknowledged the ongoing staffing challenges.