Insufficient Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on the second floor, as evidenced by multiple observations and interviews. On the day in question, only two CNAs were present for the first part of the shift due to a third CNA arriving late, and staff were unclear about their assignments. As a result, residents did not receive fresh water for two days, meal trays were delivered incorrectly or left in rooms for extended periods, and staff were unaware of which residents they were responsible for. Several residents, many with dementia or Alzheimer's disease, were observed without water within reach, with empty or outdated cups, or with no water available at all. Additionally, residents with a history of wandering were not redirected by staff, despite being observed entering and exiting multiple rooms that were not their own. Staff present in the hallway did not intervene or provide supervision. Interviews with CNAs and the RN assigned to the unit revealed that the workload was heavy, and tasks such as passing water and meal trays were delayed or not completed. The RN reported that medications were sometimes not given timely due to the workload, and agency CNAs were unfamiliar with their assignments and had not provided basic care such as water or meals to residents by mid-morning. The staffing coordinator and unit manager both confirmed that staffing was based solely on census rather than resident acuity, and that agency staff were used to fill gaps due to retention challenges. The facility's own policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved. The administrator and unit manager acknowledged that the lack of fresh water and delayed care should have been identified and addressed, but it was not recognized until brought to their attention during the survey.