Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure an adequate number of nurse aides to meet the needs of residents on the 2nd floor, as evidenced by the case of Resident R12. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a history of transient ischemic attack. The resident was assessed with severe cognitive impairment and was dependent on staff for toileting hygiene due to the left hip fracture. The care plan included interventions for skin care and repositioning every two hours due to a stage three pressure ulcer on the sacrum. On February 12, 2025, Resident R12 was found soiled with urine, and the wound dressing was also soiled, indicating neglect in care. The charge nurse discovered the issue while performing wound care. The nursing assistant, Employee E3, who was responsible for Resident R12, admitted to overlooking the resident due to being assigned eighteen patients and a lack of sufficient help. The facility's staffing sheet confirmed that the number of nurse aides scheduled was below the required state regulation, with only eight nurse aides for a census of 95 residents. The Director of Nursing confirmed the staffing inadequacy on the day of the incident.
Plan Of Correction
1. R12 has discharged from the facility. 2. The Director of Nursing or designee will educate nursing staff to review CNA assignments to divide assignments related to acuity of residents care needs. 3. The Director of Nursing or designee will conduct an initial audit of CNA assignments to ensure the assignments are divided related to acuity of residents care needs. 4. The Director of Nursing or designee will conduct weekly audits X 12 weeks of CNA assignments to review that assignments are divided related to acuity of residents care needs. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.