Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of multiple residents, resulting in missed or delayed essential care and services. Several residents did not receive scheduled showers as outlined in their care plans, with documentation and interviews confirming that some residents received showers only once or twice a month instead of the scheduled two times per week. Staff interviews corroborated that short staffing led to residents waiting until the next scheduled shower day if care could not be provided as planned. One resident reported not receiving a shower for over a month and experiencing significant delays in oral and personal hygiene assistance due to the lack of available staff for transfers requiring two people. Residents dependent on staff for transfers and participation in activities were also affected. One resident was unable to get out of bed to go outside or participate in activities as requested, missing frequent events and experiencing social isolation. Staff confirmed that covering multiple areas due to insufficient staffing made it difficult to provide timely assistance. Another resident experienced a significant delay in incontinence care, waiting over three hours after requesting help, despite facility policy requiring call lights to be answered within 5-10 minutes and peri care to be provided after voids. The DON acknowledged that such wait times were not acceptable. Residents at high risk for pressure injuries did not receive scheduled turning and repositioning interventions. Observations and documentation revealed that some residents remained in the same position for several hours without being repositioned, contrary to care plans and facility policy requiring repositioning every two hours. Staff interviews confirmed that it was not realistic to meet these requirements with the current staffing levels. These failures were observed across multiple residents with significant mobility impairments and complex medical needs, as documented in their care plans and assessments.