Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
A facility failed to provide sufficient nursing staff to meet resident needs, with multiple residents reporting delayed call light responses and transfers being completed with fewer staff than required. Residents with significant care needs, including those requiring 2-person mechanical lift transfers, toileting assistance, and hospice care, described long waits for help, missed care, and staff walking past activated call lights. The facility policy stated that each resident must receive necessary care and services and that staffing must be sufficient to meet resident assessments and care plans.
Inadequate staffing led to delayed care and unanswered call lights for two residents. One cognitively intact resident reported staff often ignored her call light and observed response times were prolonged, while another resident with cognitive impairment and toileting dependence was found soiled in bed after waiting more than an hour for help. Staff described high acuity, heavy workloads, and too few CNAs and nurses to keep up with resident care needs, with call logs showing repeated delays lasting hours.
Inadequate staffing and supervision resulted in unmet care needs and resident-to-resident altercations. A male resident with dementia who was exit seeking and wandered into other residents’ rooms required more 1:1 oversight than staff could provide, and staff reported they were unable to keep him safe while covering other duties. He was involved in multiple altercations with another resident when staffing was short. A second resident who required 2-person transfer assistance experienced repeated call light delays, with staff turning off the light before completing care and a 54-minute wait for transfer assistance. Staff and residents reported frequent call-offs, long wait times, missed breaks, and difficulty meeting resident needs when the unit was short-staffed.
A facility failed to provide enough CNA staffing and licensed nurse coverage to meet resident needs. Staff and residents reported long call light waits, delayed toileting and incontinence care, and residents being awakened early because of staffing shortages. One resident-to-resident altercation occurred while only one aide was covering the hall and the LPN was also trying to supervise the unit, leaving an injured resident with bruising, scratches, and bleeding.
The facility failed to provide enough CNA staffing to meet resident needs, and staff repeatedly reported that Unit 1 was often covered by only one aide instead of three. Residents described long waits for call lights, delayed toileting and incontinence care, missed showers, delayed repositioning, and being left in bed for hours because two staff were needed for lifts or transfers. One resident with ESRD and DM missed a dialysis appointment because there was no aide available to get her dressed and ready on time, and staff confirmed that nurses were often working as CNAs to cover shortages.
A facility failed to provide enough nursing staff and a licensed nurse in charge on each shift, leading to repeated complaints of delayed call light response, unmet toileting and transfer needs, and long waits during the night shift. Cognitively intact residents who were dependent on staff reported waits of 45 minutes to an hour or more for help, missed assistance with bed transfers and toileting, and recurring concerns documented in Resident Council minutes. The NHA acknowledged the third shift staffing problems and that the concerns had not been resolved.
Insufficient Nursing Staffing and Delayed Call Light Response: Residents reported long waits for help, delayed toileting and morning care, and repeated call light delays while the north hall was often staffed with only 2 CNAs for 24 to 28 residents and the shower aide was pulled to cover openings. A cognitively intact resident with MS, anxiety, and depression said she was often not gotten up until late morning, another resident who was legally blind reported sitting in stool or urine while waiting for help, and a third resident with diabetes and depression reported waiting more than 30 minutes and once 3 hours for bathroom assistance. Surveyors also observed active call lights left unanswered for extended periods, and 9 of 11 residents in a confidential council meeting reported regular waits of more than 30 minutes.
A facility failed to ensure enough nursing staff to timely administer meds to three residents. One resident with iron deficiency anemia and seizures, another with HTN and diabetes, and a third with HTN, a sacral pressure ulcer, and lumbar disc degeneration all reported or were found to have 9:00 AM meds delayed by several hours, with MARs showing multiple meds not documented until early afternoon. Staff reported a nurse call-off and only two nurses on the unit instead of three, and the DON acknowledged the late med concerns.
A facility failed to provide enough nursing staff to meet resident needs and ensure a licensed nurse was in charge on each shift. An alert resident reported call lights on the night shift could take up to an hour to be answered, another resident returning from dialysis was left with a cold meal tray that nursing staff did not reheat, and a guardian said daily visits were needed because the unit was frequently short-staffed. Staff interviews described CNA shortages, high turnover, and difficulty completing assigned care tasks.
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