Insufficient Staffing Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily care needs of residents, resulting in significant delays in responding to call lights and providing personal care. Multiple residents and their family members reported waiting 30 minutes to an hour for assistance with incontinence care and other needs. Certified Nursing Assistants (CNAs) were frequently unavailable due to being assigned to one-on-one (1:1) monitoring of other residents, leaving their assigned residents unattended for extended periods. In some cases, family members or private caregivers had to step in to provide care due to staff unavailability. Observations and interviews revealed that CNAs were responsible for both their assigned residents and those of colleagues who were on 1:1 monitoring, at times resulting in a single CNA being responsible for up to 19-20 residents. CNAs reported being unable to complete their duties, including providing showers, due to the additional burden of 1:1 monitoring and the lack of a dedicated shower aide. Licensed Nurses (LNs) did not assist with call lights or transfers, further exacerbating the delays in care. Resident council meeting minutes from recent months documented ongoing complaints from multiple residents about excessive wait times for assistance and staff not responding to their needs. The Director of Staff Development (DSD) confirmed that there were days when staffing levels were below the minimum required to provide adequate care, particularly on weekends with call-ins. The DSD and CNAs acknowledged that the current staffing practices, including the rotation of CNAs for 1:1 monitoring and the absence of a dedicated shower aide, resulted in neglect of other residents' needs. Facility leadership was unaware of the extent of the issue and the impact on resident care, despite documented complaints and staff concerns.