Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On several occasions, residents experienced long call light response times, with documented waits of up to 33 minutes for assistance with basic needs such as toileting and receiving water. Family members and residents reported delays in medication administration, missed meals, and untimely incontinence care. Staff interviews confirmed ongoing shortages of CNAs, CMAs, and nurses, particularly on night and weekend shifts, resulting in incomplete care tasks such as showers, vital signs, and restorative care. Staff also reported that assignments were not made timely, residents were not divided evenly, and inexperienced staff were orienting each other. Public complaints submitted to the State Agency corroborated these findings, with allegations of untimely toileting assistance, long call light response times, and inaccurate reporting of CNA hours. Facility records showed that state minimum staffing ratios for CNAs were not met on 46 out of 115 days reviewed. Staff responsible for scheduling indicated that staffing decisions were based on minimum state requirements, and upper management determined when additional staff were needed based on acuity. However, there was acknowledgment from both staff and administration of ongoing staffing challenges and frequent call-ins, especially on weekends. One resident, admitted with a history of repeated falls and depression, required substantial assistance with transfers and toileting. This resident filed a grievance regarding insufficient night shift staffing and long call light response times, which was substantiated by facility records showing a CNA shortage on the reported date. The Director of Nursing Services stated she was not involved in staffing assessments, and the administrator confirmed that no facility assessment for staffing levels based on resident acuity was available.