Failure to Maintain Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by interviews, record reviews, and direct observations. Three residents with significant care needs reported long wait times for call light responses, particularly during the night shift when staffing was lowest. One resident, with diagnoses including Multiple Sclerosis and a history of falls, described having to yell for help after falling out of bed when her call light was not answered. Another resident with mobility limitations stated that night shifts often lacked enough staff to provide timely assistance with medications and personal care. A third resident, who required assistance with activities of daily living, reported delays in call light responses and sometimes had to seek out staff herself. Staff interviews corroborated these resident accounts, with multiple CNAs stating that the facility was frequently understaffed, especially at night. CNAs reported that with only one or two staff members on duty for 47 residents, it was impossible to provide timely care, complete necessary documentation, or perform all required tasks such as repositioning, changing, and showering residents. Staff also noted that mechanical lifts could not be used safely without adequate personnel, and that some residents were left wet or not transferred as needed due to insufficient staffing. The administrator acknowledged the staffing challenges, citing a recent COVID outbreak and reliance on agency nurses, but confirmed that the facility often operated below its own assessed staffing needs. Review of staffing schedules and payroll records confirmed that on multiple occasions, only one CNA was present in the facility during overnight hours, despite the facility's own assessment indicating a need for at least 10 CNAs over a 24-hour period. The administrator admitted that she was not always notified of these staffing shortages and that the facility's budget allowed for only two CNAs on the night shift, which was not sufficient to meet resident needs. The deficiency was further substantiated by the facility assessment tool, which documented the high level of assistance required by the majority of residents for activities of daily living.