Insufficient Nursing Staff Resulting in Missed Resident Care Needs
Penalty
Summary
Facility staff failed to maintain sufficient nursing staff to meet the needs of residents on both the Dogwood and Rosewood units, as evidenced by staffing schedules and interviews. On multiple occasions, only one CNA was scheduled for the 3:00 p.m. to 11:00 p.m. shift despite a facility census ranging from 71 to 79 residents per unit. Staff interviews confirmed that the usual practice was to have two CNAs per unit during this shift, but there were times when only one CNA was present for several hours. The former staffing coordinator reported that she was not permitted to use agency staff to fill gaps, and efforts to call in additional staff were not always successful. The facility's own assessment tool indicated a need for 4-6 CNAs per unit for evening and night shifts, but this standard was not consistently met. Resident interviews revealed that snacks were not consistently provided during the night shift, with both resident council presidents from each unit stating that residents were not offered snacks. Staff interviews corroborated this, with CNAs and administrative staff acknowledging that the distribution of HS (hours of sleep) snacks was inconsistent due to insufficient staffing. The dietary department prepared and delivered snacks to the nurse's stations, but it was the responsibility of the nursing staff to distribute them, which did not always occur. The facility's policy requires sufficient staff to ensure resident safety and meet care needs, but documented staffing levels and staff accounts demonstrated that this requirement was not met on several occasions.