Failure to Provide Sufficient Nursing Staff and Essential Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints, staff interviews, and documentation reviews. Sixteen out of forty-two complaints reviewed by the Office of Health Care Quality (OHCQ) alleged inadequate staffing, resulting in essential care such as showers, toileting, and changing not being provided. Several residents reported not receiving scheduled showers for extended periods, with documentation confirming missed or unoffered showers over several months. Staff interviews corroborated these findings, with geriatric nursing assistants (GNAs) stating that when staffing levels were low, they were unable to provide showers or complete other necessary care tasks. Further review revealed that the lack of adequate staffing also impacted other aspects of resident care. In one instance, a nurse was unable to change a resident's dressing due to being the only nurse for 40 residents, resulting in the dressing not being changed as scheduled. Additional complaints and grievance logs documented residents being left in soiled briefs for extended periods, with staff confirming that high resident-to-staff ratios made it impossible to provide timely care, including answering call bells and performing regular rounds. Staff consistently reported that when there were call outs or insufficient GNAs, care tasks such as showers and meal service could not be completed as required. Analysis of staffing schedules and records showed that the facility repeatedly failed to meet the state-mandated minimum of 3.0 hours of bedside care per resident per day (PPD). For multiple periods reviewed, the facility's staffing hours fell below this threshold, with some days as low as 2.31 PPD. The staffing coordinator acknowledged ongoing difficulties in maintaining adequate staffing levels, particularly after the facility stopped using agency staff, and noted frequent challenges in securing registered nurses for night shifts. These deficiencies had the potential to affect all residents in the facility.