Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were scheduled and available to meet the needs of all residents, as evidenced by multiple resident and staff interviews, record reviews, and staffing schedules. Several residents, all of whom were cognitively intact and required significant assistance with activities of daily living (ADLs) such as toileting, bathing, dressing, and transfers, reported frequent and prolonged delays in having their call lights answered, particularly during night shifts and weekends. Residents described waiting up to an hour for assistance, especially when two-person assistance was required, and noted that staffing levels were noticeably lower on weekends compared to weekdays. Staff interviews corroborated these concerns, with CNAs and nurses reporting that there were often only three CNAs in the building during night shifts, despite a significant number of residents requiring two-person assistance. Staff also indicated that when scheduled CNAs called in absent, they were not consistently replaced, resulting in even fewer staff available to provide care. The Director of Nursing acknowledged that the facility ideally needed four CNAs per night shift but confirmed that this was not always achieved, particularly on weekends. Staff described being unable to complete all required care tasks, such as showers and timely response to call lights, due to insufficient staffing. Review of staffing schedules and facility census confirmed that on several documented dates, only three CNAs were scheduled to care for 60 residents, 35 of whom required two-person assistance for care and transfers. The facility's own policy required sufficient staff to assure resident safety and maintain the highest practicable well-being, but the documented staffing patterns did not meet these needs. The deficiency was further substantiated by the facility's own records and the consistent reports from both residents and staff regarding inadequate staffing and delayed care.