Failure to Provide Timely ADL Assistance Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), including bathing and incontinence care, for eight residents reviewed for ADL needs. Multiple residents with significant medical conditions such as diabetes, hemiplegia, heart disease, cognitive impairment, and mobility deficits were dependent on staff for essential care. Documentation and interviews revealed that scheduled showers were frequently missed, and residents often experienced delays in receiving incontinence care and assistance with toileting. Care plans for several residents lacked specific interventions for bathing or toileting, and scheduled shower lists were not consistently followed. Residents and their family members reported that insufficient staffing led to long wait times for assistance, sometimes up to an hour, resulting in missed showers and incontinent episodes. Several residents stated that there were not enough CNAs on duty, especially during certain shifts, which directly impacted the timeliness and frequency of care provided. Observations included residents with greasy hair and foul body odor, and staff interviews confirmed that short staffing made it difficult to complete scheduled showers and respond to call lights promptly. Staff also reported that on some occasions, only one CNA was available for the entire facility, making it impossible to meet all residents' needs in a timely manner. The facility's own staff, including CNAs and nurses, acknowledged the ongoing staffing shortages and the resulting inability to provide timely ADL care. Some staff described working shifts with only one or two CNAs, which was insufficient to complete all required care tasks, including showers and incontinence care. Documentation of care provided was also inconsistent, with some staff admitting to forgetting to fill out shower sheets. The administrator confirmed that the facility often operated with fewer CNAs than ideal, and that nurses were sometimes required to assist with direct care due to the lack of available CNAs.