Insufficient Nursing Staff Leads to Missed Care
Penalty
Summary
The facility was found to have insufficient nursing staff to provide necessary personal care and related services, impacting the well-being of seven residents. Interviews with nursing aides revealed that they often felt understaffed, particularly during the second shift, which affected their ability to provide adequate care, including scheduled showers for residents. This staffing issue was corroborated by resident interviews, where concerns were raised about the lack of staff to provide adequate care. Clinical record reviews for the affected residents showed that scheduled shower tasks were not completed as planned. For instance, Resident 5, diagnosed with dementia and depression, did not receive a shower on a scheduled day, as indicated by the 'not applicable' marking in their records. Similar patterns were observed for other residents, such as Resident 6, who missed showers on multiple occasions, and Resident 7, who did not receive a shower on a scheduled day. These lapses in care were consistent across several residents, all of whom had specific medical conditions requiring regular attention. The Nursing Home Administrator was unaware of why staff marked 'not applicable' instead of 'refused' for missed showers, indicating a lack of clarity or training in documentation practices. The administrator acknowledged the issue and mentioned plans to educate staff on proper documentation. However, the report focuses on the deficiency in staffing and its direct impact on resident care, as evidenced by the missed showers and staff and resident testimonies.
Plan Of Correction
1. This event cannot be corrected as it is a past event. 2. Unit Managers have assumed responsibility of providing CNA's at the start of each shift their shower assignment and the nurse assigned to the hallway must ensure showers were provided and documented appropriately; calculation of shift CNA deployment will be completed daily for accuracy by the DON/Designee. 3. Nursing education provided on the responsibilities of meeting the highest practicable residents' physical, mental and psychosocial needs; education provided to Nursing Administration regarding monitoring appropriate CNA deployment on each shift. Education provided to On-Call Manager, RN Supervisor and Scheduler to review steps to be taken when call offs; Utilization of a new external recruiting group for hiring purposes, increased agency rates, tuition reimbursement, referral bonus and incentive bonus' offered all designed to assist the facility in meeting the needs of the residents. 4. 10 random shower audits on off shifts completed weekly x4 weeks, then monthly x2. CNA deployment will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 01/14/2025.