Failure to Maintain Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were always available to meet residents' needs and to have a licensed nurse in charge on each shift. During a facility tour, surveyors found that no specific person was designated as in charge, and nursing staff were unclear about who to contact in case of an emergency. The staff board listed unit supervisors, but none were present on the units during the survey. Interviews with nursing staff revealed uncertainty about supervisory coverage, particularly on weekends. Multiple staff members reported that staffing shortages, especially on weekends, resulted in increased resident assignments for CNAs and LPNs. CNAs described having to care for more residents than usual due to staff call-outs, with some reporting assignments of 12 or more residents. An LPN reported being responsible for 30 residents at times. Staff consistently indicated that these staffing patterns led to rushed care and difficulty meeting residents' needs. The DON acknowledged awareness of low weekend staffing and recent management changes.