Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. Several residents reported extended wait times for call light responses, with one resident stating it could take 30-40 minutes for staff to respond, particularly noting their room was at the end of the hallway. Another resident indicated that staffing levels seemed low, and others described having to wait a long time for assistance without specifying exact durations or shifts. A family member reported that their loved one was left on the toilet for extended periods and that they often had to seek staff assistance in the hallway, especially during mealtimes and weekends. Staff interviews corroborated these concerns, with nursing assistants and other staff members stating that the facility was short-staffed on all shifts. One nursing assistant noted a reduction in the number of staff on their shift, from seven to five, and described delays in providing two-person assistance for residents with higher acuity needs. Continuous observation of call light panels revealed that several call lights remained illuminated for extended periods, with some not being answered for over 15 to 26 minutes. During these times, staff were observed entering rooms without call lights on, and residents were seen waiting for assistance with basic needs such as transferring, bed-making, and napping. The staffing coordinator and facility leadership confirmed that staffing levels were determined based on census and a per patient day (PPD) formula, with adjustments made as census increased. However, staff and anonymous sources indicated that the current staffing did not meet the acuity needs of residents, particularly in halls with a higher number of residents requiring two-person assistance. This deficiency was identified as a repeat citation, indicating ongoing issues with maintaining adequate nursing staff to meet resident needs.