Failure to Provide Adequate Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple resident and staff interviews, record reviews, and direct observations. Several residents, all of whom were cognitively intact and dependent on staff for activities of daily living such as toileting, transferring, and personal hygiene, reported excessive wait times for call light responses, particularly on weekends. One resident described waiting over an hour for assistance on a Sunday, while another reported a 30-minute wait after activating the bathroom call light, followed by an additional 15-minute delay before being helped off the toilet. These delays were corroborated by staff interviews and direct observation of a resident's call light being ignored for an extended period while staff walked past the room. Staff interviews consistently indicated that staffing levels, especially on weekends and certain shifts, were insufficient to meet resident needs in a timely manner. CNAs and nurses reported working alone on halls with up to 30 residents, making it difficult to answer call lights promptly, complete required care tasks, and provide timely assistance with activities such as getting residents out of bed, passing supper trays, and performing two-person transfers. Staff described situations where they had to pull nurses away from medication administration to assist with resident care due to the lack of available CNAs. Multiple staff members stated that with only one CNA per hall, it was not feasible to meet all resident needs promptly, particularly during busy periods such as meal times and when families were visiting. Review of facility staffing schedules confirmed that on several occasions, including weekends and holidays, the number of CNAs and nurses scheduled was below the facility's stated expectations and insufficient to cover the resident population. The Director of Nursing acknowledged that the facility did not have a call light policy but expected call lights to be answered within 10 to 15 minutes, and agreed that 30-minute wait times were not timely. The facility's own assessment tool stated that staffing should be based on resident needs and acuity, but the documented schedules and staff accounts demonstrated that this standard was not consistently met, resulting in unmet resident needs and delayed care.