Insufficient Weekend and Night Staffing Leading to Missed and Delayed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available each day to meet resident needs according to their plans of care, particularly on weekends and during evening/night shifts. Review of grievances over a six‑month period documented confirmed incidents of missed or delayed care, including a resident not receiving incontinence care between 6:00 PM and 6:00 AM and being found wet the next morning, and another resident reporting that his catheter bag was allowed to fill to 2,000 mL before a CNA arrived to empty it. Additional grievances confirmed long call‑light wait times, rushed care by CNAs, and delays in getting residents out of bed when two‑person assistance was required. A three‑week staffing schedule review showed consistently lower total staffing hours on weekends compared to weekdays, while the census remained relatively stable. Residents and family members reported that staffing was low on weekends, that staff were not available when needed throughout the day, and that rooms were often unorganized and residents not ready for scheduled outings. Residents who normally ate in the independent dining room reported being required to eat in the assisted dining room on weekends due to lack of supervision, and this was corroborated by a kitchen whiteboard stating the independent dining room was closed on Saturdays and Sundays. During interviews, night‑shift licensed nurses reported that each wing had one CNA and one nurse on duty and acknowledged that between 4:00 AM and 6:00 AM residents might wait longer for assistance as more residents began calling for help. A CNA stated the facility was often low‑staffed on weekends and not always appropriately staffed from 6:00 PM to 10:00 PM, resulting in longer wait times to meet resident needs. The staffing coordinator confirmed that staffing was based on census and that the facility did not have many weekend staff. Resident council feedback further documented repeated concerns about low weekend staffing, closure of the independent dining room on weekends, and staff observed sitting at the nurses’ station charting while call lights remained unanswered.
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