Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to monitor and deliver timely care to residents, as evidenced by multiple direct observations, interviews, and record reviews. During a lunch period on the Alzheimer's unit, a resident with severe cognitive impairment and incontinence repeatedly requested assistance to use the bathroom but was told by staff that they could not help her immediately due to being occupied with feeding other residents. The resident became visibly upset, cried out for help, and ultimately soiled herself after waiting for an extended period without assistance. Other residents were observed wandering unsupervised, attempting to exit the facility, and eating food from other residents' plates, indicating a lack of adequate supervision and timely care. Staff interviews confirmed that the unit was short-staffed due to a CNA leaving early, leaving only two CNAs and a patient aid (PA) present. Staff consistently reported that this level of staffing was insufficient to meet residents' needs in a timely manner, especially during busy periods such as mealtimes. Staff also described being unable to stop feeding residents to provide other necessary care, and noted that administrative and nursing staff were not available to assist during these times. The PA stated she was not permitted to provide direct care, further limiting the available support. The nurse manager and DON acknowledged the chaotic environment and agreed that more staff would be beneficial, particularly during meals and evenings. Additional documentation and interviews revealed similar staffing concerns on other units and shifts, including night shifts where a nurse was shared between two units and only two CNAs were present. Staff described delays in responding to alarms, providing incontinence care, and assisting residents with activities of daily living. One resident experienced a fall when staff were occupied elsewhere and alarms were not heard in time. Multiple staff members and residents reported that care was not provided in a timely manner due to inadequate staffing, and assignment sheets confirmed the low staffing levels. The facility's own policy stated that adequate staffing would be maintained to meet residents' needs, but this was not observed in practice.