Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents and staff/resident interviews. One resident, who was moderately cognitively impaired and required supervision for activities of daily living, experienced a fall in the bathroom after becoming dizzy and was found on the floor by a CNA. The resident's care plan specifically required that she not be left unattended in the bathroom or while sitting on the side of the bed, and that her call light be kept within reach with prompt response to requests for assistance. On the night of the fall, there was only one nurse and one CNA assigned to the hallway where this resident and others resided. Other residents and staff reported that there was not enough help on the night shift, with only one nurse and one CNA typically assigned to certain halls, making it difficult to provide timely care and supervision. Residents who were dependent on staff for transfers and mobility, and those at risk for falls, expressed concerns about insufficient staffing, particularly during evening and night shifts. Staff assignment sheets confirmed that on several reviewed dates, only one nurse and one CNA were assigned to the relevant hallways during overnight hours. Additional documentation, including grievance forms and resident council meeting minutes, indicated ongoing concerns about call lights not being answered promptly and the need for CNAs to check on residents every two hours. The facility's staffing plan referenced CMS minimum staffing guidelines and described a methodology for determining staffing needs, but interviews with the scheduler and administrator revealed that staffing decisions were based on these minimums and the facility assessment, without a specific policy for nursing staff levels.