Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across all four units, as evidenced by multiple resident interviews, staff interviews, observations, and record reviews. Several residents reported excessive wait times for assistance after activating call lights, with one resident waiting up to an hour and a half and another waiting two hours for help with toileting. These residents had significant medical needs, including hemiplegia, heart failure, muscle weakness, and impaired mobility, and some were unable to perform activities of daily living without staff assistance. Observations also revealed residents left unattended in common areas, including one resident attempting to stand unsafely from a wheelchair and another struggling to move his wheelchair without staff present. Resident Council meeting minutes over several months documented ongoing concerns about delayed call light responses, indicating a persistent issue. A resident representative expressed frustration about unaddressed falls and unanswered call lights, particularly on weekends. Staff interviews consistently described chronic staffing shortages, unpredictable assignments, and difficulty completing tasks, especially during weekends and meal times. Staff members reported frequent call-offs and described staffing as 'hit or miss,' with some stating they had become accustomed to the inadequate staffing levels. The staffing coordinator and DON acknowledged that staffing decisions were primarily based on numbers rather than resident needs, and admitted that required staffing levels were not always met, particularly on weekends and certain shifts. Despite daily reviews of staffing with the NHA and SC, the DON stated being unaware of any staffing concerns. The facility's policy required sufficient staff to meet resident needs according to care plans, but the evidence showed this standard was not consistently met, resulting in unmet resident needs and delayed care.