Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically impacting one resident who required assistance with activities of daily living. On one occasion, a resident was observed sitting on the side of the bed with a walker in front of him, his call light out of reach, and his foot in a puddle of urine. The resident reported waiting for over an hour for help to transfer to a chair and to be cleaned up. Staff confirmed that they were unable to assist the resident promptly due to staffing shortages and the need for two people to safely transfer the resident, resulting in prolonged waiting times. Interviews with staff revealed that the unit was frequently staffed with only one nurse and two CNAs for 24 residents, despite the need for more personnel to provide adequate care, especially for residents requiring two-person assistance. Staff members expressed concerns about heavy workloads and the inability to provide timely care, with one CNA stating that they would not risk moving a resident alone due to fall risk. The Assistant DON acknowledged that the unit should have two nurses and two CNAs on the AM shift, but coverage was often insufficient due to call-offs and difficulty securing agency staff. A review of staffing schedules for the month showed that the unit was short one nurse on 28 out of 31 days for the AM shift. Facility policies require sufficient staffing to meet residents' needs and ensure call lights are within reach, but these standards were not consistently met. The resident involved had diagnoses including muscle weakness, unsteadiness, and a history of falls, and was cognitively intact, further highlighting the impact of inadequate staffing on resident care and dignity.