Insufficient Staffing Led to Unsupervised Resident Interactions During Meals
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents in the memory support unit, resulting in multiple incidents where residents consumed food or beverages from other residents' plates or cups without intervention. Observations revealed that one resident with severe cognitive impairment and a history of Alzheimer's Disease, dementia, and dysphagia repeatedly took and drank from other residents' cups in the dining area when no staff were present. Staff were only alerted to these incidents by the surveyor, after which the contaminated cups were discarded. Another resident with severe cognitive impairment was observed eating food from the plates of two other residents before being served her own meal, causing visible agitation in one of the affected residents. Only one of the affected residents received a replacement meal, while the other did not. Interviews with staff indicated that the unit was typically staffed with three or four CNAs for 32 residents, and staff reported difficulty supervising all residents, especially when providing care in individual rooms. Staff from the activities department were noted to assist with supervision, but only one activities staff member was present at a time, making it challenging to monitor both dining rooms simultaneously. Staff consistently reported that more personnel were needed to adequately supervise and assist residents, particularly those with behavioral issues or cognitive impairments. A resident interview described the environment on weekends as chaotic due to insufficient staffing, further corroborating the observations and staff statements. The lack of adequate supervision directly contributed to the incidents where residents consumed food or beverages from others' plates or cups, and to the overall disorder in the unit, affecting the quality of care for all residents in the memory support unit.