Failure to Meet Required Nursing Staff Hours Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the required 3.5 direct care service hours per patient day (DHPPD) for 27 out of 39 days reviewed. This deficiency was evidenced by observations, interviews, and record reviews, which showed that residents did not receive timely nursing care. For example, one resident with cerebral palsy, stroke, dementia, and hemiplegia was observed unable to reach his call light and stated that it took a long time to get help. Another resident, who was completely blind and had diabetes and retinopathy, reported that it often took between thirty minutes to an hour to receive assistance, especially at night and on weekends, sometimes requiring him to call out or go to the nursing station himself despite his blindness. Certified Nursing Assistants (CNAs) interviewed confirmed that staffing was often insufficient, with one CNA responsible for up to 15 residents and feeling unable to provide adequate care. The Director of Nursing verified that the facility's DHPPD was below the required level on most days reviewed, and acknowledged that call lights were not being answered within the expected 15-minute timeframe. The facility's staffing waiver also required a minimum of 3.5 DHPPD, which was not met on numerous days as documented in the reviewed records.