Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple observations, interviews, and record reviews. Several residents were observed waiting extended periods for assistance after activating their call lights. One resident was seen with his call light on for an extended period before it was answered by a corporate nurse, while another resident reported waiting up to an hour for assistance and missing scheduled activities due to the delay. Staff interviews confirmed that there were only four CNAs working on the day of observation, which was considered insufficient by both staff and residents. Residents with varying degrees of physical and cognitive impairment were directly affected by the staffing shortage. One resident, who required assistance with eating, was left with an untouched meal tray for over an hour and only received help after a family member and a staff member intervened. Another resident, dependent on a mechanical lift for transfers, reported long waits for assistance and instances of incontinence due to delays. A CNA admitted to performing a mechanical lift transfer alone, contrary to policy, because no other staff were available to help. Additional observations included a resident with a bed alarm and call light out of reach, who was left unattended while urgently needing to use the restroom. The resident attempted to use a trashcan to urinate after calling for help for several minutes without response. Staff interviews consistently indicated that the current staffing levels were inadequate to meet resident needs, with some care tasks, such as showers, being missed on short-staffed days. The facility's own staffing policy and administrator statements confirmed that the number of CNAs present was below the ideal level, and the issue was exacerbated by staff absences due to illness.