Failure to Maintain Sufficient Nursing Staff and Scheduling
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, resulting in significant lapses in care and resident safety. Multiple interviews and record reviews revealed that the facility did not provide any working nursing staffing sheets or schedules when requested, and staff reported that no one was actively making the schedule. Staff were left to call each other for coverage, and there was no consistent use of agency staff despite a contract being in place. On several occasions, nurses and CNAs worked for over 30 consecutive hours without relief, and at one point, the building was left with only two staff members to care for 44 residents overnight. There were also periods when the building was left unattended for short durations. Staff interviews indicated that the lack of adequate staffing led to residents being left wet and soiled for extended periods, with some residents not being changed since early morning hours. Residents expressed concerns for their safety and well-being, reporting that they were unable to get assistance when needed and felt unsafe due to the absence of staff. The police were called to the facility after residents made multiple calls regarding their safety, and the police subsequently contacted the Department of Health and Senior Services. Staff also reported that the facility had not maintained staffing sheets for a long time, and the only time a staffing sheet was seen was during a state complaint investigation. The deficiency was further corroborated by statements from the facility's medical director and physician, who both indicated that two staff members were not sufficient to care for the resident census and that they expected the facility to have a working schedule and staffing sheet. The business office manager and other staff confirmed that the facility only had two nurses employed at the time and that the lack of a schedule had persisted for weeks. The administrator acknowledged the staffing shortages and the inappropriateness of leaving only one staff member in the building, as well as the absence of a working schedule prior to their arrival.