Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by multiple reports of delayed responses to call lights, late medication administration, and unmet activities of daily living (ADL) needs. Several residents reported waiting 30 minutes to over an hour for staff to respond to call lights, resulting in discomfort, emotional distress, and, in some cases, incontinence episodes. Residents and their families noted a decline in staffing levels and care quality following a recent change in facility ownership, with an increased reliance on agency staff unfamiliar with residents' needs. Documentation and interviews revealed that on specific days, the facility operated with only half the required number of licensed nurses and was also short on certified nursing assistants (CNAs). This staffing shortage led to residents not being assisted out of bed, not being dressed, not receiving timely wound care, and not having their bed linens changed. Medication administration records showed that medications were given several hours late, and some residents did not receive necessary blood sugar checks or insulin as scheduled. Staff interviews confirmed that the facility was aware of impending staffing shortages but was unable to secure adequate coverage, and that the situation caused significant frustration among both staff and residents. Residents with complex medical needs, such as those with pressure ulcers, diabetes, and cognitive impairments, were particularly affected. Family members reported concerns about late medications and unmet care needs, leading to at least one resident being discharged to another facility. Staff, including LPNs and the nursing staff coordinator, described the situation as "horrible" and "hellish," with some staff responsible for an unmanageable number of residents and medication carts. The facility's own policies and facility assessment indicated that staffing should be based on resident acuity and care plans, but these standards were not met during the period in question.