Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record reviews, staff interviews, and direct observations. Staffing schedules showed that Licensed Nursing Assistants (LNAs) on light duty with lifting restrictions were counted as full-duty staff and assigned full workloads. On multiple occasions, there were shifts where only one LNA was present on a unit, or where two LNAs on light duty were scheduled together, resulting in inadequate coverage for the number of residents, including those requiring two-person assistance for transfers. Staff interviews consistently reported that the number of LNAs was insufficient to complete required tasks such as showers, transfers, and timely response to call lights, with some staff refusing to work due to unsafe staffing levels. Direct observations and staff accounts indicated that residents were not receiving necessary care, such as showers and assistance with transfers, due to the lack of available staff. Residents dependent on mechanical lifts or two-person assists often had to wait extended periods for care, and some were left in bed or in geriatric chairs for prolonged times. The dining room was frequently closed because of inadequate staffing, and residents were grouped together in rooms for meals instead. Staff also reported an increase in resident falls and that residents were missing outside specialist appointments and meaningful activities because there were not enough staff to assist them. Resident council minutes and interviews with residents confirmed ongoing concerns about insufficient staffing, long waits for care, and missed showers. Residents expressed frustration with the lack of available staff, particularly during evening and night shifts, and reported going extended periods without showers. The facility's failure to adjust staffing assignments to account for light duty restrictions and to ensure adequate coverage for resident care needs directly contributed to these deficiencies.