Insufficient Staffing Resulting in Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by direct observation, interviews, and record review. On the evening in question, several Certified Nursing Assistants (CNAs) did not report for their scheduled shifts, resulting in inadequate staffing levels. One CNA was observed transferring a resident with dementia, muscle weakness, and vision loss using a mechanical lift without the required assistance of another staff member, as specified in the resident's care plan and physician orders. The CNA stated she performed the transfer alone because other CNAs were occupied with other residents and there was not enough staff available at the time. Multiple staff interviews confirmed that the facility was short-staffed that evening, with only two CNAs and a nurse on one unit with 35 residents, and two CNAs and a nurse on another unit with 17 residents, instead of the typical three to four CNAs per unit. Staff reported that this shortage led to delays in answering call lights, providing incontinence care, and monitoring resident behaviors. The Assistant Director of Nursing acknowledged that staffing is only sufficient when there are no call-ins, and the Administrator was not aware of the staffing shortage at the time. The facility's staffing policy requires sufficient numbers of staff to meet resident needs in accordance with care plans and facility assessment.