Failure to Provide Sufficient Nursing Staff Resulting in Unsafe Resident Assignments and Fall Incident
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its own policy and Facility Assessment Tool, resulting in certified nursing assistants (CNAs) being assigned more residents than permitted on multiple occasions. Specifically, on several dates, CNAs working the night shift in Station 3 were assigned between 24 and 25 residents each, despite the facility's policy and assessment indicating that no CNA should be assigned more than 12 residents per shift. Interviews with CNAs and facility leadership confirmed that this was a recurring issue, with staff reporting that such assignments made it impossible to provide safe and effective care, including timely repositioning, changing, and ensuring a safe environment for residents. On one morning shift, the facility assigned only five CNAs to Station 3 when the Facility Assessment Tool recommended seven. During this shift, a resident with morbid obesity and acute respiratory failure, who was dependent on staff for all transfers and personal care, experienced a fall while being transferred with a Hoyer lift. The CNA operating the lift did so alone, contrary to the facility's policy requiring two staff for such transfers. The CNA reported not asking for help due to the short staffing and the high workload. The resident fell from the lift, striking their head and leg, and required transfer to an acute care hospital for evaluation. Interviews with the resident, involved staff, and facility leadership confirmed that the short staffing directly contributed to the incident. The resident described the fall as traumatic and painful, noting that typically two staff would assist with Hoyer lift transfers, but only one was available due to staffing shortages. Facility leadership acknowledged that the staffing levels on the cited dates did not meet the facility's own standards or the needs of the residents, and that such staffing patterns posed a significant risk to resident safety.