Insufficient Nursing Staff Resulting in Missed Care and Delays
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by staffing levels falling below the facility's own assessment of desired staffing on eleven out of ninety shifts during the review period. Documentation from daily staffing sheets showed multiple instances where the number of certified nurse aides and nurses on duty was significantly less than what was outlined in the facility assessment. As a result, residents did not receive showers as scheduled, were left in bed for extended periods, and were not able to participate in planned activities. Staff, residents, and family members consistently reported that low staffing led to delays in care, with some residents waiting up to two hours for assistance, and staff being unable to take breaks due to the workload. Interviews further confirmed the impact of inadequate staffing, with residents stating they missed showers and were left in bed because staff were too busy. Staff members reported that on certain shifts, especially weekends and nights, the number of aides was insufficient to provide care for all residents, sometimes leaving only three aides to care for forty residents. The Human Resource Director and Administrator acknowledged awareness of staffing shortages, particularly on weekends, and confirmed that the daily staffing sheets accurately reflected these deficiencies.