Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the daily needs of residents, resulting in multiple instances where residents did not receive timely assistance with activities of daily living (ADLs) such as meal service, toileting, bathing, dressing, medication administration, and getting out of bed. On several hallways, CNAs were either absent or stretched thin, with one CNA responsible for up to 13 residents and others covering multiple hallways. Staff interviews and observations revealed that residents were left in bed for extended periods, some in soiled briefs, and meals were often left untouched and out of reach. Medication administration was also delayed or improperly managed, with medications left at bedside and not always given as scheduled. Residents reported and were observed experiencing delays in receiving care, including not being assisted out of bed, not having briefs changed, and not receiving baths or meals in a timely manner. Several residents expressed that these issues were more pronounced on weekends due to staff call-offs and insufficient backup plans. Staff members confirmed that low staffing levels were a recurring problem, with some CNAs not receiving breaks or lunch due to the workload. The facility's own records indicated that staffing levels frequently fell below the numbers outlined in the facility assessment, and the administrator was not familiar with the required hours per resident day (HPRD) or how to calculate them. Documentation showed that the facility did not consistently meet its own staffing plan, with numerous days where the number of CNAs on duty was below the required minimum for each shift. The facility assessment identified a high percentage of residents needing extensive assistance with ADLs, yet the actual staffing did not align with these needs. Staff and resident interviews, as well as direct observations, confirmed that the lack of adequate staffing led to unmet care needs, delays in assistance, and compromised resident well-being.