Insufficient Staffing Leads to Delays and Incomplete Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff interviews and direct observations. Staff consistently reported that only one CNA was assigned per villa, with occasional floaters available on certain days, but not consistently throughout the week. CNAs were responsible for a wide range of duties, including resident care, transfers requiring two staff, toileting, showers, cleaning, laundry, meal preparation, and activities. Staff described frequent situations where they had to wait for assistance from a nurse or another staff member to perform tasks requiring two people, such as mechanical lifts or transfers, resulting in delays in care and incomplete tasks. Some staff admitted to skipping or abbreviating showers and cleaning due to time constraints, and residents sometimes had to wait for care or assistance. Direct observations confirmed that at times, only one CNA and one nurse were present in a villa, and there were periods when no staff were visible because they were assisting residents in their rooms. Residents requiring two-person assistance for transfers or mechanical lifts were present, and staff expressed concerns about resident safety, particularly for those at risk of falls. One resident reported being left alone in a villa with no staff present and would have to seek help if needed. Staff also indicated that the workload was overwhelming, especially when floaters were not available, and that management did not assist with direct care tasks. A specific incident involved a resident with Alzheimer's disease and dementia, identified as an elopement risk, who was able to leave the courtyard unsupervised because the only nurse on duty was in another villa and the CNA was assisting another resident. The resident was found outside the villa by staff after ringing the doorbell, and the courtyard gate was found unlocked. Staff noted that wander guards had been discontinued, and the lack of sufficient supervision contributed to the resident's unsupervised exit. Additionally, staff reported difficulty in providing required showers and daily care for residents needing two-person assistance, sometimes resulting in only partial care being provided.