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 on both the North and South halls, as evidenced by multiple observations, interviews, and record reviews. Residents with high acuity and total dependence on staff for activities of daily living (ADLs), such as bathing, mobility, and eating, experienced significant delays and inadequate care. For example, one resident with severe cognitive impairment and total dependence was repeatedly left waiting for meals, sometimes for extended periods, and was not consistently assisted with eating or provided with timely beverages. Bathing records showed this resident received only two baths in 22 days, despite care plans indicating a need for more frequent showers. Staff interviews confirmed that only one CNA was assigned to the dining room during meals, when ideally three were needed, resulting in delayed assistance for residents requiring help with eating. Another resident, who required extensive assistance with a bedpan and preferred morning showers, reported not receiving timely care and had to call the facility for help when call lights were not answered. Documentation and interviews revealed that this resident's requests for assistance were not promptly addressed, with call lights left on for up to an hour and staff stating they did not have time to provide care due to other duties. Resident council minutes and concern forms further corroborated ongoing issues with long call light response times, late meals, and missed showers, with residents attributing these problems to short staffing. Grievances submitted by the resident council regarding staffing concerns were not documented as being acted upon. Staff interviews consistently described an environment of inadequate staffing, high resident acuity, and insufficient supplies, leading to delays in care, incomplete ADLs, and increased staff stress. Staff reported difficulty finding assistance for two-person transfers, inability to complete showers as scheduled, and having to perform tasks outside their roles due to lack of available CNAs. Some staff admitted to transferring residents alone when two were required, and therapy staff noted that basic care was often not completed before rehabilitation sessions. Management interviews acknowledged the use of a census tool to determine staffing needs and challenges in hiring CNAs, but staff and residents continued to report unmet care needs and insufficient staffing.