Insufficient Staffing Leading to Delayed Resident Assistance and Unsafe Transfers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by resident council notes, facility assessment, and interviews with residents and staff. The facility assessment documented staffing ratios of 1 LPN/RN to 15 residents on the day shift, 1 LPN to 30 residents on the overnight shift, 1 CNA to 10 residents on day and evening shifts, and 1 CNA to 15 residents on the overnight shift. Residents and staff reported that these staffing levels were inadequate, particularly on the overnight shift, resulting in delayed assistance for residents. One resident reported waiting up to 40 minutes for help, which led to incontinence episodes and feelings of humiliation, especially while managing a urinary tract infection. Staff interviews confirmed that there were often only two CNAs on the morning and evening shifts and only one CNA on the overnight shift. Staff acknowledged that due to insufficient staffing, mechanical lifts were sometimes operated by a single staff member, contrary to safe transfer practices, and that call lights were not answered promptly. The facility was unable to provide policies regarding call light response times and the use of mechanical lifts, and corporate staff did not provide requested policies after a change in facility ownership.