Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents where residents were not checked or changed in a timely manner, experienced excessively long call light wait times, and were not assisted with activities of daily living (ADLs) according to their care plans. Several residents, including those with severe cognitive impairment, incontinence, and high assistance needs, reported or were observed to have been left soiled for extended periods, not repositioned or transferred as required, and not provided with timely toileting assistance. Incident investigations and interviews revealed that residents frequently waited up to an hour or more for assistance, and staff were often unable to find help for two-person care tasks due to inadequate staffing levels. The facility's own assessment indicated a high proportion of residents with incontinence and mobility impairments, yet staffing decisions were based on census rather than acuity, as confirmed by the staffing coordinator and administrator. Staff interviews and observations showed that nursing assistants were responsible for caring for a high number of residents, and agency staff were used daily to fill gaps. Staff and residents consistently reported that the facility was short staffed, especially on the North (100 hall, LTC) unit, which was described as "heavy care" and not adequately staffed to meet resident needs. Residents were observed eating meals in bed and not being gotten out of bed as care plans required, with documentation showing missed transfers and lack of adherence to physician orders for out-of-bed time. Incident logs from several months documented numerous allegations of neglect, abuse, and resident-to-resident altercations, many of which were related to unmet care needs and long response times. Resident council meeting minutes and interviews with residents and family members further corroborated concerns about insufficient staffing, long wait times, and unmet care needs. Staff statements confirmed difficulty in obtaining assistance for care tasks requiring two staff, and the inability to provide timely care due to being "way behind" or unable to leave other residents unattended. The facility's failure to ensure adequate staffing placed all residents at risk for avoidable accidents, unmet care needs, and diminished quality of life.