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 all residents, as evidenced by multiple observations, interviews, and documentation reviews. Residents reported not receiving scheduled baths, experiencing long wait times for call light responses, and not receiving timely assistance with toileting needs. For example, one resident with a left below-knee amputation and significant assistance needs stated he was only receiving one bath per week instead of the scheduled two, and sometimes went two weeks without a shower. He also described waiting up to 45 minutes for help during the day and having accidents due to delayed assistance, particularly at night when staff would turn off his call light while he was asleep without providing care. Another resident, who was dependent on staff for bathing and dressing, reported receiving a bath only once a month, despite preferring weekly baths. He also described long waits for call light responses, sometimes up to an hour, resulting in accidents while waiting for help with toileting. Observations confirmed that his fingernails were long and dirty, and a strong odor was present during care, indicating lapses in personal hygiene assistance. Staff interviews corroborated these issues, with CNAs and LPNs acknowledging that baths and other care tasks were often missed or delayed due to insufficient staffing, especially when only one or two CNAs were present on a shift. Resident council notes and grievance forms further documented ongoing concerns about inadequate staffing, missed baths, and long call light response times. Staff described a routine of passing missed baths to the next shift and documenting 'NA' when baths were not completed due to staffing shortages. The Director of Nursing confirmed that staffing levels were often insufficient, leading to delays or missed care, and that baths would be postponed when there were not enough staff members available. Housekeeping and laundry staff also reported finding residents soaked in bed in the mornings, particularly after night shifts with minimal staffing.