Failure to Provide Adequate Staffing and Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate supervision and unsafe care for multiple residents with high acuity and complex care requirements. Staffing levels were determined by census and minimum regulatory requirements, rather than by the actual acuity and care needs of the resident population. Staff interviews and resident council feedback confirmed that the facility was routinely short-staffed, leading to excessively long call light wait times, delayed responses to resident needs, and staff being required to perform duties outside their roles to compensate for shortages. The staffing guide used by the facility was based on headcount rather than resident acuity, and staff frequently reported being overworked and unable to provide adequate supervision, especially during night shifts and when 1:1 monitoring was required. Three residents experienced significant harm as a result of these staffing deficiencies. One resident with severe cognitive impairment and behavioral issues was involved in repeated resident-to-resident altercations and sustained multiple falls, resulting in serious injuries including a dislocated hip, femur fracture, and back fracture. Despite being placed on frequent safety checks and having care plan interventions, the resident continued to experience falls and altercations, with care plans not being reviewed or revised after each incident. Another resident, dependent on staff for toileting and transfers, fell multiple times, sustaining fractures to the eye socket and leg, and was left unattended on the toilet despite care plan instructions. A third resident with dementia and a history of frequent falls experienced 36 falls over a year, resulting in various injuries and hospital transfers, with care plan interventions not consistently updated after each fall. Documentation and interviews revealed that the facility did not consistently review or revise care plans following incidents, and staff were unable to provide the level of supervision required for residents at high risk for falls or with behavioral challenges. Grievance logs and resident council feedback highlighted ongoing concerns about insufficient staffing, long wait times for assistance, and unmet care needs. Staff acknowledged that some falls and altercations could have been prevented with adequate staffing, and that the facility's reliance on agency staff and minimum staffing guides was insufficient to address the actual needs of the resident population.