Staffing Shortages Lead to Missed Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed assistance with bathing, incontinence care, and personal hygiene for four of eight sampled residents. Multiple staff interviews confirmed that staffing shortages, particularly on weekends, led to an inability to get residents out of bed, provide scheduled showers, and deliver timely incontinence and hygiene care. Staff reported that when short-staffed, their focus shifted to only essential tasks such as keeping residents clean, dry, and fed, with other care needs being delayed or omitted. Medication aides and nurses described being assigned to multiple halls and being unable to complete medication passes on time due to inadequate staffing. Nurse aides reported difficulty serving meals, making regular rounds, and responding promptly to call lights. The staffing scheduler and former interim DON acknowledged ongoing challenges with staff call-outs and no-shows, which left shifts uncovered despite efforts to use agency staff and administrative support. The facility's attempts to adjust shift lengths and scheduling practices did not consistently resolve the staffing gaps. Residents participating in a council meeting also voiced concerns about weekend staffing shortages, noting that showers were missed and call lights were answered more slowly. The administrator and staffing scheduler confirmed that the number of nurse aides and nurses on duty was often below the preferred minimums, especially on weekends and certain shifts, and that open positions remained unfilled. These staffing deficiencies directly resulted in unmet resident care needs as observed and reported during the survey.