Failure to Maintain Adequate Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where staffing levels fell below the facility's own staffing plan and regulatory requirements. On several occasions, there was only one certified nurse aide assigned to units with over 30 residents during the night shift, and nurse supervisors were frequently not present during evening and night shifts. Staffing records showed inconsistencies, with staff not completing full shifts, coming in late, or leaving early, and callouts were often not replaced. These staffing shortages led to delays in care, such as long wait times for call bell responses, incomplete turning and repositioning, and residents not being assisted out of bed or returned to bed as needed. Specific incidents highlighted the impact of inadequate staffing on resident care and safety. On one night shift, a resident sustained a fall when only one LPN was present on the unit due to a callout that was not covered, and no nurse supervisor was in the building. Another resident dislodged their urinary catheter and did not receive timely assistance, with a fellow resident having to stay with them for two hours until the morning shift arrived. Staff interviews confirmed that when only one aide was present on a unit, essential cares were not completed, residents were left wet, and medication administration was delayed. Staff also reported that they were often required to work double shifts, skip breaks, and manage unmanageable workloads due to chronic understaffing and unreliable scheduling. Residents and their representatives expressed concerns during council meetings about the lack of responsiveness to call bells, missed or rushed care, and the particular challenges during overnight shifts. The facility's Director of Nursing and Administrator acknowledged ongoing recruitment challenges, frequent callouts, and the difficulty in maintaining adequate staffing, especially for night shifts. Despite being aware of these issues, the facility did not adjust staffing based on resident acuity or ensure that callouts and shift changes were effectively managed, resulting in repeated instances where resident care and safety were compromised.