Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, staffing schedule reviews, and direct observations. Residents reported excessive wait times for assistance with activities of daily living (ADLs), including toileting, changing, and ambulation. Several residents described waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions for extended periods. Staff confirmed that they were frequently short-staffed, with some shifts having only one CNA and a nurse covering the entire unit, leading to delays and incomplete care such as missed baths and repositioning. Staffing schedules reviewed showed that minimum staffing requirements were not met for 23 out of 31 days reviewed. Specific incidents included a resident being left on a bedpan for several hours overnight, ultimately having to remove it themselves, which resulted in a spill that was discovered by the nurse. Other residents reported being told by staff to limit their use of call bells due to short staffing, and some residents experienced a decline in mobility because staff were unable to assist with walking. Staff interviews corroborated these accounts, stating that care was not being provided in a timely manner and that residents were sometimes left in soiled beds. The deficiency was discussed with the Director of Nursing and the Administrator.