Failure to Provide Adequate Nursing Staff Results in Delayed Care and Resident Harm
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple incidents involving insufficient aide coverage, delayed response to call lights, and unmet care needs. On one occasion, a resident with range of motion impairment and requiring assistance for toileting was left on a bedside commode for approximately an hour and a half, despite activating the call light and eventually using a cell phone to call for help. Staff interviews confirmed that only one aide was available for an entire floor of residents during the shift in question, resulting in significant delays in care and frustration among residents. Staff also reported that management was notified of the staffing shortages, but the situation persisted, with aides and nurses expressing concerns about the unsafe staff-to-resident ratios and the inability to provide timely care. Another resident experienced a fall resulting in a wrist fracture after attempting to remove a wet incontinence pad from their bed due to delayed assistance. Documentation and staff interviews indicated that there were only two aides on the floor during the night shift prior to the fall, and the post-fall review noted the absence of a midnight aide to perform regular checks and changes. The resident, who was cognitively intact, reported pain and was sent to the emergency department for evaluation. Staff further described ongoing issues with inadequate staffing, including the removal of housekeeping staff from non-care tasks such as meal tray delivery, which increased the burden on nursing aides and contributed to delays in resident care and meal service. Review of facility records, including staffing schedules, assignment sheets, and the facility assessment, revealed that staffing decisions were primarily based on census numbers rather than resident acuity. Although the facility's policy stated that staffing should account for acuity and care needs, there was no evidence that acuity was factored into actual staffing assignments. Staff consistently reported that the number of aides and nurses was insufficient to meet the needs of residents with higher acuity, leading to late medication administration, delayed toileting and hygiene care, and increased risk of adverse events.