Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, observations, and review of facility records. Staff reported frequent instances where Certified Nursing Assistants (CNAs) were left alone on the floor, especially during weekends and night shifts, resulting in delayed or missed care such as bathing, oral care, feeding assistance, and incontinence care. Staff also described situations where tasks requiring two staff members, such as Hoyer lift transfers, were performed by a single staff member due to inadequate staffing. Observations confirmed that call lights often went unanswered for extended periods, and residents expressed frustration with long wait times for assistance, sometimes exceeding an hour. Residents reported feeling unsafe, particularly during night shifts, and described incidents where they were not assisted with mobility aids, leading to fear of falls and actual accidents. Several residents stated that their personal care preferences, such as timely showers and the ability to choose their clothing, were not being met due to staff rushing through care. Staff interviews further revealed that the lack of adequate staffing led to poor quality and untimely care, with some residents not receiving regular incontinence care, turning, or repositioning as required. Staff also reported that nurses were often pulled away from medication passes to assist with resident care, causing further delays. A review of the facility's assessment tool indicated that the number of full-time and part-time nursing staff employed was insufficient to meet the needs of the current resident population, particularly those who were fully dependent on staff for activities of daily living (ADLs) such as dressing, bathing, transferring, and toileting. The Director of Nursing and Facility Administrator confirmed that, based on the facility assessment, the current staffing levels were not adequate to provide timely and quality care to residents. The deficiency was substantiated through direct observation, staff and resident interviews, and review of facility documentation.