Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff on 16 out of 45 reviewed shifts in the subacute unit, resulting in unmet care needs for 59 out of 67 sampled residents. These residents, many of whom had complex medical conditions such as respiratory failure, tracheostomy tubes, and ventilator dependence, required substantial or total assistance with activities of daily living, including showering, toileting, and transfers. Despite the facility's policy and facility assessment specifying staffing ratios and the assignment of a dedicated shower nurse, staffing shortages were frequent due to call-offs and unfilled positions, leading to the absence of a shower nurse and increased resident assignments for CNAs. Multiple interviews with staff confirmed that when CNAs were assigned 10 to 14 residents each, or when the shower nurse was pulled to cover other assignments, showers and other personal care tasks were not completed. Staff reported being overwhelmed and unable to provide scheduled showers, bed baths, or even routine oral care as required. Documentation of showers was only possible through completed shower sheets, and when these were missing, there was no evidence that care was provided. Residents also reported not receiving scheduled showers or bed baths, and experiencing significant delays in call light responses, particularly during night shifts when staffing was especially low. A review of staffing records revealed repeated instances where the number of CNAs on duty fell below the facility's stated goals, with some shifts having as few as two or three CNAs for over 50 residents. The facility's own policies and facility assessment outlined specific staffing ratios and the need for a shower nurse, but these were not consistently met. The Director of Nursing acknowledged that care and showers must be provided regardless of staffing levels, and that insufficient staffing should not be an excuse for unmet resident needs.