Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of all residents, as evidenced by multiple missed or delayed care events. Several residents with significant medical conditions, including diabetes, hemiplegia, cognitive impairment, and mobility deficits, did not receive scheduled showers or timely incontinence care. Documentation showed that residents dependent on staff for activities of daily living (ADLs) such as bathing and toileting often missed scheduled showers, sometimes going up to six days without bathing, and experienced delays in call light response, resulting in incontinence episodes. Interviews with residents revealed consistent concerns about inadequate staffing, with reports of long wait times for assistance, missed showers, and insufficient help with toileting. Some residents reported waiting up to an hour for staff to respond to call lights, and several stated that they had experienced incontinence episodes due to these delays. Observations by surveyors confirmed instances of poor hygiene, such as greasy hair and foul body odor, and staff interviews corroborated that low staffing levels made it difficult to provide timely care, especially during shifts with only one or two CNAs present. Review of facility records, including timecards and schedules, confirmed that there were multiple shifts with only one or two CNAs available to care for approximately forty residents. Staff members, including CNAs and nurses, reported being unable to complete all scheduled showers or respond to call lights promptly during these periods. The facility's assessment tool did not specify staffing requirements tailored to the facility's needs, further contributing to the deficiency in meeting resident care needs.