Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of its residents, as evidenced by prolonged call-light response times and delays in assistance with care needs. Interviews with residents, family members, and staff revealed that residents often waited up to an hour or more for help, particularly with toileting and incontinence care. One resident with an overactive bladder reported frequent episodes of incontinence due to long wait times, while another resident, who required extensive assistance due to a tracheostomy and anoxic brain damage, had to rely on a privately hired sitter because staff were not available to provide timely care. Staff interviews confirmed that excessive call-ins and staff shortages were common, resulting in high resident-to-CNA ratios, especially on weekends and night shifts. Certified Nurse Assistants and LPNs reported caring for as many as 15 to 16 residents each, with many residents requiring two-person assistance due to high acuity and total-care needs. The Director of Nursing, Assistant Director of Nursing, and Administrator all acknowledged ongoing staffing concerns, frequent complaints from residents and families, and the inability to consistently cover shifts when staff called in. Review of staffing records showed that on several occasions, only three or four CNAs were available per shift to care for nearly 90 to 95 residents across multiple wings, including a specialized tracheostomy unit. The facility's own policy required sufficient and competent nursing staff to meet resident needs, but interviews and documentation demonstrated that this standard was not met, resulting in delays in care and unmet resident needs.