Failure to Provide Sufficient Nursing Staff Resulting in Unmet Care Needs and Pressure Ulcers
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to meet the care needs of residents, particularly those residing on the ventilator and tracheostomy hallways. Staffing records and interviews revealed that, at times, only three CNAs and three RNs were present to care for all residents on these high-acuity units, with most residents requiring two-person assistance for activities of daily living (ADLs). Staff reported working extended shifts, sometimes up to 18 hours, and being unable to take breaks or complete all required care tasks, such as turning and repositioning residents every two hours. Multiple CNAs confirmed that it was not possible to provide all necessary care due to the heavy workload and insufficient staffing levels. Several residents experienced negative outcomes as a result of inadequate staffing. One resident, who was dependent on staff for all ADLs and assessed as a fall risk, suffered an unwitnessed fall after attempting to get out of bed when incontinent, as they were unable to use the call light and staff could not provide timely assistance. Another resident, also fully dependent and rarely understood, was observed multiple times in the same position in bed and developed a stage 4 pressure ulcer that worsened during their stay. Staff interviews confirmed that residents were not being turned and repositioned as required, and necessary equipment such as heel boots was not consistently available or used. A third resident, admitted with a stage 3 sacral pressure ulcer, developed additional facility-acquired pressure ulcers, including a deep tissue injury on the heel and a pressure ulcer on the ear. Observations and interviews with family and staff indicated that this resident was not being turned or repositioned regularly, and care plan interventions such as the use of heel boots and pressure-relieving mattresses were not consistently implemented. The DON and Administrator acknowledged the worsening of wounds and the lack of consistent interventions but did not provide explanations for the failures. Staff repeatedly stated that the high acuity and total care needs of residents, combined with insufficient staffing, made it impossible to meet required care standards.
Plan Of Correction
Element 1: The facility assessment has been updated by 5/14/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to needs not being met by the Director of Nursing/Designee by 5/14/25. Residents' concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 5/14/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 5/14/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 5/14/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including sufficient staff resident needs. This education will be completed by 5/14/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.