Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews involving four residents. One resident with a history of acute osteomyelitis, diabetes, chronic kidney disease, and recent partial foot amputation reported waiting 20 to 40 minutes for call lights to be answered, especially when needing assistance with transfers and toileting. The resident and her spouse stated that dirty laundry remained in the room for days, and showers were missed or delayed due to inadequate CNA staffing. Documentation confirmed infrequent showers, and the resident reported ceasing to request help due to long wait times. Another resident, dependent on staff for toileting following a recent shoulder replacement, described waiting 15 to 30 minutes for call lights to be answered and being left on a bedpan for extended periods. Direct observation by the surveyor confirmed a call light was left unanswered for 28 minutes. Staff interviews revealed that only one CNA was assigned to the unit, who was also responsible for meal tray delivery, leaving no one to answer call lights during meal service. Staff expressed confusion and concern about how to manage both responsibilities simultaneously. Additional residents, including one with quadriplegia and another dependent on staff for all ADLs, reported similar issues with delayed responses to call lights, missed showers, and being left on bedpans for prolonged periods. Staff interviews consistently indicated that recent staffing cuts by new facility ownership resulted in only one CNA per unit, increased workloads, and an inability to provide timely care. Staff and residents reported increased complaints, missed care tasks, and a decline in quality of care. Nursing staff also noted an increase in resident falls and pressure ulcers since the staffing reductions.