Insufficient CNA Staffing Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient Certified Nursing Assistant (CNA) staffing to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. On a specific day, only 7 CNAs were present, distributed as 3 on the East wing, 2 on the Middle wing, and 2 on the West wing, which did not meet the facility's own staffing plan of 8 CNAs for the day shift. Resident Council Meeting Minutes over several months documented ongoing concerns about delayed call light responses, water not being passed in the evenings, and missed showers on scheduled days. The facility's assessment indicated a significant number of residents with stage three or four pressure ulcers and a census of 83 residents, with 41 requiring two-person assistance for transfers or care. Staffing sheets confirmed that multiple day and night shifts were staffed below the facility's stated minimums. Staff interviews corroborated the insufficient staffing, with CNAs and a Registered Nurse reporting frequent short-staffing, increased workloads, and difficulty in providing timely care, including repositioning residents and responding to call lights. The Director of Nursing confirmed that actual staffing did not match the facility's staffing plan and acknowledged the challenges in maintaining adequate coverage due to call-offs and recent staff resignations. The deficiency affected all residents in the facility, particularly those requiring higher levels of assistance.