Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to consistently provide sufficient nursing staff to meet the care needs of its residents, as evidenced by multiple documented instances of staffing shortages across various shifts. Review of nursing schedules and daily work logs over a one-month period revealed repeated occasions where the number of aides and nurses who actually worked was less than the number scheduled. These shortages affected both day and night shifts, with some shifts missing up to three scheduled staff members. Resident council meeting minutes and grievance forms over several months documented ongoing concerns from residents and families regarding delayed call light responses, missed showers, late meal service, and inadequate incontinence care, particularly on weekends and holidays. Specific resident accounts highlighted the impact of these staffing shortages. One resident reported waiting 1.5 hours for assistance to use the restroom, resulting in an accident, and described infrequent bathing and long periods without staff contact overnight. Another resident stated that he waited 85 minutes for his call light to be answered, which led to soiling himself, and later had to use a bell for several days while his call light was being repaired, with response times averaging 50-60 minutes. Additional grievances included a resident left in feces for 50 minutes and call lights being turned off by staff without providing assistance. These accounts were corroborated by observations of residents with unmet hygiene needs and by staff interviews acknowledging the challenges of delivering timely care when short staffed. Interviews with facility staff and administration revealed a lack of a formal policy for call light response times and inconsistent awareness of staffing issues. The scheduler stated that all call-offs were covered and was unaware of any staffing problems, while a former CNA described days when staff struggled to deliver meals, answer call lights, and provide basic care. The Assistant DON stated that staff are expected to answer call lights within 3-5 minutes, but this expectation was not consistently met. The facility's own assessment indicated that residents required substantial to maximal assistance with bathing and toileting, yet the documented staffing levels and resident reports demonstrated that these needs were not reliably met.