Failure to Provide Sufficient Nursing Staff Resulting in Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delays in activities of daily living (ADL) care, skin care treatments, and incontinence care, as well as negatively impacting residents' dignity. Multiple residents and family members reported long wait times for assistance after pressing call lights, with some residents waiting up to 45 minutes for help with toileting, leading to incontinence accidents and emotional distress. Staff interviews confirmed that there were frequent staffing shortages, with only one Certified Resident Care Assistant (CRCA) often assigned to a hall, making it difficult to complete scheduled showers, skin care, and other essential care tasks in a timely manner. Staff members, including RNs, LPNs, and CRCAs, described an ongoing pattern of inadequate staffing, with frequent call-offs and management being unresponsive to urgent staffing needs. On one occasion, there was a documented 40-minute period when no nurse was present in the building, and staff had to rely on a nurse who had already worked a 16-hour shift and was attempting to leave. Staff reported being unable to complete required documentation, such as admission and skin assessments, and were sometimes instructed by management to backdate records to cover missed care. Resident Council meeting minutes over several months consistently reflected concerns about short staffing, delayed medications, and missed showers. The deficiency was further substantiated by time sheet reviews and interviews with the facility scheduler, who confirmed ongoing issues with filling shifts and the impact on resident care. The lack of adequate staffing led to missed or delayed care, falsification of shower records, and increased resident behaviors due to unmet needs. The survey cited related deficiencies in ADL care, quality of care, and resident dignity, with specific examples of residents not receiving timely shaving, skin care treatments, and respectful incontinence care.