Failure to Maintain Sufficient Staffing to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the basic needs and ensure the safety of all residents, as evidenced by staff schedules, time punches, and multiple interviews. On several nights, staffing levels fell below the facility's own minimum requirements, with as few as one or two staff members present for 56 residents during overnight shifts. There were instances where only non-certified staff or a single CNA was present, and on some nights, the only staff in the building were not certified to provide direct resident care. The written schedules often did not match the actual staff present, and non-certified staff were instructed to perform resident care tasks for which they had not been trained. Residents with significant care needs, including those with Parkinson's Disease, a history of falls, rheumatoid arthritis, spinal stenosis, and cognitive communication deficits, reported long waits for call lights to be answered, missed or delayed baths, and delays in receiving medications and meals. Residents described waiting 30-45 minutes or longer for assistance, not receiving regular hygiene care, and experiencing late or cold meals due to insufficient staff to distribute trays. Staff interviews corroborated these accounts, with CNAs and CMTs reporting that they were frequently the only caregivers on the floor, leading to delays in care, missed medications, and residents not being laid down or changed in a timely manner. Non-certified staff, including housekeepers and environmental services personnel, were directed to assist with resident care tasks such as transferring and feeding residents, despite lacking proper training or certification. Staff described being overwhelmed, unable to complete all required tasks, and sometimes having to perform two-person transfers alone. Observations confirmed that many residents remained in bed past scheduled times for breakfast, and soiled linens were noted by laundry staff. The administrator acknowledged the staffing shortages and stated that he or she had to cover shifts as a charge nurse and come in at night when no nurse was available.