Failure to Provide Sufficient Nursing Staff and Maintain Resident Care Standards
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by only two certified nursing assistants (CNAs) being assigned to care for over 150 residents during a night shift, despite the facility assessment indicating that approximately nine CNAs were needed. Both CNAs reported being solely responsible for their respective units, with one caring for residents who were mostly ambulatory and the other for residents requiring significant assistance with activities of daily living and incontinence care. Management was notified of the staffing shortage, but no additional staff were called in or arrived to assist during the shift. The Director of Nursing confirmed the inadequate staffing and that the usual number of CNAs for the shift was five to six. Multiple observations and interviews revealed that resident care and facility conditions were negatively impacted by the staffing shortage. Residents were found in unsanitary conditions, such as rooms with gnats, dirty showers, and soiled floors. Some residents did not receive timely assistance with personal hygiene, and there were instances of unsupervised residents in common areas. Medication administration was also affected, with LPNs and RNs assigned to large numbers of residents, leading to late or undocumented medication administration. Medication carts were observed left unlocked and unattended, and there were discrepancies between physician orders and medication administration records. Additional deficiencies included the lack of a licensed nurse with the required training to manage the facility's restorative program, as the assigned nurse had not completed the necessary coursework. Residents with specific needs, such as those requiring fall prevention interventions or assistance with prosthetic devices, did not always have appropriate equipment or interventions in place. Housekeeping staff also reported being unable to maintain cleanliness due to staffing issues, and maintenance concerns such as water leaks were observed. The facility's own policies and assessments indicated the need for higher staffing levels and outlined procedures for addressing shortages, which were not followed during the documented events.