Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On a day when the census was 53 residents, staffing lists showed a significant number of residents required two-person assistance for transfers, bathing, toileting, and dressing, as well as one-to-one feeding assistance and bariatric care. On a specific night shift, only two CNAs were present for 50 residents, which staff and family members confirmed was inadequate to meet resident acuity needs. This staffing shortage was directly linked to incidents such as a resident fall and delays in care. Throughout several days of observation, call light response times were excessively long, with some call lights going unanswered for up to 47 minutes. Residents were observed waiting for assistance with activities of daily living (ADLs), including toileting and going to bed, for extended periods. Some residents reported waiting up to two hours for help, and staff confirmed that chronic understaffing led to missed showers, delayed care, and inability to complete rounds or provide timely assistance. The lack of functioning call light monitors and staff not carrying required devices further contributed to delays in care. Specific residents experienced negative outcomes due to insufficient staffing. One resident with an ostomy reported multiple incidents where their ostomy bag burst due to delayed assistance, resulting in soiling themselves and their bed. Another resident, dependent on staff for all ADLs, reported long waits for care, especially during night shifts. Staff interviews consistently indicated that staffing was based on state minimum ratios rather than resident acuity, and that frequent call-offs and lack of agency coverage exacerbated the problem. Resident Council meeting minutes and direct resident feedback highlighted ongoing concerns with slow call light response and staff not returning after initial contact.