Failure to Provide Sufficient Nursing Staff Resulting in Delayed Response to Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff, including both CNAs and nurses, to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. During facility tours, staffing levels were observed to be as low as 2 CNAs and 2 nurses, and later 5 CNAs and 3 nurses, for 81 residents. Residents reported inadequate staffing, with one resident stating that increased use of agency staff indicated a need for more permanent staff. Another resident described multiple falls, including an incident where he was unable to reach his call light after falling, crawled to the hallway without finding staff, and ultimately called 911 for assistance. First responders, including fire and police personnel, reported difficulty locating staff upon arrival, eventually finding a nurse and another staff member outside smoking, both unaware of the resident's situation. Documentation showed that on the day of the incident, scheduled staffing was not met, with fewer CNAs present than planned. The resident involved in the fall was found on the floor with dried blood on his hands, face, and head, and had been attempting to get staff attention with a broken coat hanger. The nurse on duty reported last checking on the resident approximately 45 minutes before first responders arrived but did not enter the room. The facility's staffing policy requires sufficient licensed and unlicensed staff to maintain residents' well-being, but records and staff interviews confirmed that staffing levels were inadequate at the time of the incident.