Failure to Provide Sufficient Nursing Staff to Meet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the total care needs of all residents, as evidenced by multiple observations, interviews, and record reviews. The Payroll Based Journal (PBJ) Staffing Report indicated a one-star staffing rating, and the Facility Assessment (FA) was incomplete, lacking identification of contributors, QAPI review documentation, and a detailed staffing plan based on resident acuity. Staff interviews consistently reported inadequate staffing, with CNAs and nurses unable to complete timely resident care, including incontinence checks, medication administration, and assistance with activities of daily living (ADLs). Observations confirmed that actual staffing levels did not match posted schedules, and staff were often left to care for more residents than they could manage effectively. Several residents with significant care needs were directly affected by the staffing shortages. One resident, dependent on staff for toileting and hygiene, was found saturated with urine after not receiving incontinence care for several hours. Another resident, also incontinent and requiring assistance, was observed with a saturated brief and stale-smelling urine, with staff unable to recall the last time care was provided. A third resident with hemiplegia and significant weight loss was left unattended in the dining room, not receiving timely assistance with eating, despite care plans indicating the need for such support. Additionally, a resident with obesity and immobility was found lying in urine-soaked bedding, having not been changed since early morning, despite requests for assistance. Staff interviews corroborated these findings, with CNAs and nurses reporting that they were unable to meet residents' needs due to insufficient staffing. The Director of Nursing acknowledged that staffing levels met only the minimum required hours and did not align with the posted schedule or the actual needs of residents. The facility's own policy emphasized resident-centered care, but the lack of adequate staffing and incomplete facility assessment resulted in residents not receiving timely and appropriate care, particularly for those requiring frequent incontinence checks and assistance with meals and mobility.