Insufficient Nursing Staff Resulting in Delayed ADL Care and Poor Resident Hygiene
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily needs of all residents, resulting in delays in activities of daily living (ADL) care and laundry services. Multiple residents reported having to wait extended periods for assistance, particularly on weekends and night shifts. Observations confirmed that call lights remained unanswered for several minutes, and staff were often not present in hallways or at the nurses' station. Residents described incidents where they were told to manage on their own until staff could assist, leading to accidents and frustration. One resident with frequent diarrhea due to antibiotics was told to use a brief instead of a bedpan, resulting in soiling of a wound vacuum, which caused pain during changes. Direct observations throughout the week revealed that some residents remained in bed, undressed, and in soiled conditions for extended periods. For example, one resident with a gastrostomy tube was observed in a hospital gown all week, with poor hygiene, greasy and matted hair, and signs of inadequate oral care. This resident was found with a strong odor of urine and bowel, and her bedding and clothing were soaked with urine and feces. Another resident was observed in similar conditions, with greasy, matted hair and spending most of the week in bed in a hospital gown. Residents and the Resident Council consistently reported insufficient staff, missed showers, and lack of available linens, especially on night shifts. Staff interviews corroborated these findings, indicating that staffing levels were often inadequate, particularly when there were call-ins or unfilled shifts. CNAs reported difficulty keeping up with care needs, especially on high-acuity halls, and noted that laundry staff reductions led to shortages of clean linens and washcloths. Payroll and staffing records showed low staffing hours per resident, especially on weekends and holidays, with some shifts providing less than 30 minutes of direct care per resident. Despite these issues, facility leadership did not recognize a staffing problem and had not implemented any quality improvement plans to address the ongoing concerns.