Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff at all times to meet the needs of residents, as evidenced by multiple resident and family interviews, staff interviews, and direct observations. Residents and their families reported frequent and prolonged delays in receiving assistance, particularly with incontinence care and response to call lights, especially during evening and night shifts. Several residents described waiting from two to eleven hours to be changed, with one resident developing a urinary tract infection (UTI) as a result of delayed care. Family members and residents also noted a high turnover of staff and a lack of adequate training among new staff members. Staff interviews confirmed that the facility often operated with only two nursing assistants (NAs) for the entire building, even when the census was close to 60 residents. Staff reported working extended shifts, sometimes up to 19 hours, and being called in on their days off to cover shortages. Restorative aides were pulled from their usual duties to provide basic care due to staffing shortages. Staff also indicated that nurses rarely assisted with call lights or direct care, further exacerbating delays in resident care. Direct observations by surveyors corroborated these reports, including an incident where a resident waited over 40 minutes for assistance after activating a call light, and was found covered in emesis. Review of staffing records confirmed that on multiple dates, only two NAs were scheduled for shifts covering the entire facility. These deficiencies affected all residents in the facility and were substantiated by both documentation and firsthand accounts.