Failure to Provide Sufficient Staffing for Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically impacting a resident with multiple medical conditions including congestive heart failure, diabetes mellitus, COPD, and a history of stroke. This resident was cognitively intact but dependent on staff for showering, with physician orders specifying showers on certain days during the night shift. Documentation and interviews revealed that the resident did not receive scheduled showers on two occasions when staffing was short, with only one CNA available to cover two houses, each housing up to 12 residents. The resident expressed that showers were missed when staffing was inadequate, and preferred to have showers early in the morning. Review of facility records confirmed the absence of documentation for the missed showers, and the DON verified that if there was no documentation, the shower was not completed. The facility's own assessment indicated that five CNAs were required for the third shift, but on the shift in question, only four CNAs were present, and one called out, leaving insufficient staff to meet resident needs. Facility policy stated that residents should be assisted with bathing to maintain hygiene and prevent skin issues, but this was not followed due to inadequate staffing.