Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several care deficiencies. One resident with a pressure ulcer on her right upper leg reported that her dressing was not changed consistently, particularly during the day when staff stated they did not have time. Medical record review confirmed that the wound was not assessed, measured, or monitored for nearly a month, and a Wound Clinic note documented that the pressure injury worsened during this period. Staff interviews corroborated that dressing changes were not completed as ordered and that wound care documentation was lacking. Other residents experienced unmet needs related to activities of daily living (ADLs) and long call light response times. One resident was often left in her room in the dark during breakfast, missing opportunities for socialization and encouragement to eat. Another resident reported waiting an hour and a half to be changed and stated that basic hygiene tasks such as face washing and hair brushing were inconsistently performed. Observations confirmed that at times, no CNAs were present on the floor, and staff reported that the unit was frequently staffed with only one nurse and two CNAs for 34 rooms, with some residents requiring two-person assistance for transfers. Multiple residents and staff expressed concerns about low staffing levels, with reports of call lights going unanswered for extended periods and residents feeling reluctant to request assistance. Staff described being floated to other buildings and feeling short-staffed more than half the time. The call light system was also reported to be down, preventing the facility from providing call light response data. These staffing shortages directly contributed to delays in care, incomplete ADLs, and inadequate repositioning for residents at risk of skin breakdown.