Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. Residents experienced significant delays in call light responses, with documented wait times ranging from 23 to 45 minutes, and in some cases up to an hour. Several residents, all with unimpaired cognitive status, reported frequent and prolonged waits for assistance, leading to episodes of incontinence and unmet hygiene needs. Staff interviews confirmed that nursing personnel were required to work overtime or extra shifts regularly, often foregoing breaks, and struggled to complete their duties due to inadequate staffing levels. Staff also reported that care tasks such as hygiene and meal service were delayed or rushed because of insufficient personnel. Family members and residents filed grievances regarding the lack of timely care and insufficient staff presence, particularly during shift changes and nighttime hours. One family representative noted that residents were not always repositioned as needed, and staff confirmed that there were not always enough personnel to safely operate equipment such as Hoyer lifts. Grievances documented that some staff refused to answer call lights at night, citing facility rules, and residents continued to express concerns about staffing even after grievances were filed. These findings collectively demonstrate a pattern of inadequate staffing that compromised residents' physical, mental, and psychosocial well-being.