Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of all residents, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents with complex medical conditions, including diabetes, morbid obesity, chronic obstructive pulmonary disease, chronic pain, and mobility impairments, reported frequent and prolonged delays in receiving assistance, particularly with activities of daily living (ADLs) such as toileting, showering, and repositioning. Residents consistently described long wait times for call light responses, especially during evening, night, and weekend shifts, with some reporting waits of up to two hours. Staff interviews corroborated these accounts, with multiple CNAs and nurses stating that the facility was regularly short-staffed, particularly on night shifts and weekends. Staff reported difficulty completing required rounds and providing timely care, with some stating that showers and other essential care tasks were often missed due to inadequate staffing. Assignment records confirmed that on several occasions, only one nurse and two CNAs were present to care for all 47 residents during overnight shifts, which was below the facility's own assessment of required staffing levels. Despite these findings, facility leadership, including the Administrator and DON, maintained that staffing was adequate, though they acknowledged occasional reliance on agency staff and admitted to shifts with only two CNAs and one nurse. The facility did not have a formal staffing policy in place. The deficiency was identified through direct resident and staff testimony, review of care plans and assignment sheets, and census data, all of which demonstrated a pattern of insufficient staffing that affected the ability to meet residents' care needs.