Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. The facility assessment indicated a staffing plan that included seven nurses and ten CNAs per day, but payroll-based journal data showed a one-star staffing rating for the second quarter. Several residents did not receive scheduled showers, and both staff and residents reported frequent delays in care, including long wait times for call light responses and missed appointments. Staff interviews confirmed that there were not enough aides at times, and the removal of a dedicated shower aide further impacted the ability to provide timely care. Direct observations revealed that call lights remained unanswered for extended periods, with some residents waiting over 30 minutes for assistance. Meal trays were also delayed, and there were instances where no aide was present on a unit, leaving only a nurse to manage care and medication administration. Staff were observed being unaware of the absence of assigned aides, and the DON confirmed that call lights should not go unanswered for more than 30 minutes, yet this expectation was not met. Staff also reported difficulties in obtaining assistance for two-person tasks and noted that aides were frequently no-call, no-shows, leaving units understaffed. Resident interviews corroborated these findings, with reports of waiting up to 90 minutes for care and call lights going unanswered for significant periods. One resident reported forgetting the reason for activating the call light due to the long wait, despite having a medical concern to report. Policy reviews indicated that the facility was expected to provide timely responses to resident needs, with a goal of responding to call lights within five minutes, but this standard was not achieved. The deficiency was investigated under a specific complaint number and affected all residents in the facility.