Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple instances where only two CNAs were scheduled on shifts when the facility's own assessment identified the need for three. This staffing shortfall directly impacted resident care, resulting in delayed responses to call lights, missed restorative services, and the inability to accommodate scheduled smoke breaks for dependent residents. The facility's call light logs and resident interviews documented numerous occasions where call lights went unanswered for extended periods, sometimes up to 56 minutes, particularly during meal times and shift changes when staffing was especially inadequate. Several residents with significant care needs, including those with quadriplegia, contractures, chronic pain, and high dependency for activities of daily living, experienced delays in receiving assistance. For example, one resident who required pain medication reported waiting up to 40 minutes for staff to respond to their call light, often when requesting pain relief. Another resident, dependent on staff for all mobility and at risk for aspiration, did not receive regular range of motion (ROM) exercises due to the absence of a restorative program, and staff confirmed that no one was designated to provide these services. Residents and their families consistently reported dissatisfaction with the timeliness of staff response, especially during busy periods. Additionally, a resident who required a mechanical lift and staff supervision to smoke was unable to participate in scheduled smoke breaks because staff were occupied with other care duties. This resident expressed distress over missing smoke breaks and waiting long periods for assistance, with staff confirming that care priorities and limited staffing made it difficult to accommodate such requests. Staff interviews corroborated these findings, acknowledging the challenges of meeting resident needs with insufficient personnel, particularly during high-demand times. The facility's leadership also recognized the lack of adequate staffing and the absence of a restorative program, further contributing to unmet resident needs.