Failure to Maintain Sufficient CNA Staffing and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available on a specific evening shift, resulting in unmet care needs for a resident who was fully dependent on staff for toileting and hygiene. On that evening, two CNAs who were scheduled to work were unavailable: one CNA called off for the shift, and another CNA, a registry staff member, left early and did not return. No replacement staff were secured for either CNA, and the facility was unable to produce accurate documentation of how CNA assignments were regrouped or redistributed after these staffing losses. As a result, there was no documented reassignment for the resident care groups that included the affected resident’s room. The resident involved had diagnoses including constipation and Ogilvie syndrome and was documented as always incontinent of bowel and dependent for toileting and hygiene per the MDS Section GG and Section H. The resident was cognitively intact, with a BIMS score of 14, and resided on Station 1. On the evening in question, the resident reported becoming soiled due to her medical condition and activating the call light for assistance. She stated that the registry CNA assigned to her care left early and did not return, and that she waited approximately two hours after activating the call light before receiving help. During an interview and observation, the resident became teary while recounting the event and explained that managing her uncontrollable bowel movements was difficult. Multiple staff interviews and record reviews corroborated the staffing and response issues. Review of the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET confirmed that one registry CNA called in and another registry CNA signed in for the shift but left early and did not clock in or out, with no replacement staff identified. The DSD, IP, and Human Resources/Maintenance Director confirmed there was no documentation of revised CNA assignments for the affected resident groups after the staffing changes. Staff, including a CNA who was not assigned to the resident, reported that call lights were not consistently answered that evening and that multiple call lights were observed unanswered. This CNA responded to the resident’s call light, found the resident crying and in a soiled brief, and observed that the resident’s skin appeared red when she was changed. Facility policies reviewed indicated that staffing should be sufficient and competent to meet resident needs, call lights should be answered within 3–5 minutes, registry staff should follow facility protocols and documentation requirements, and residents should be treated with respect, kindness, and dignity.
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