Failure to Provide Adequate Staffing Resulting in Missed Care and Hygiene Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in missed showers, extended wait times for assistance, and unmet personal hygiene needs. Multiple residents, including those with significant medical conditions such as enterococcus bacteremia, neuropathy, traumatic brain injury, and incontinence, reported long delays in response to call lights and infrequent bathing. One resident stated that it took over 45 minutes for staff to respond to his call light, while another was unable to brush his teeth or access personal hygiene items due to lack of staff assistance. Family members and residents consistently reported frustration with the lack of timely care. Observations and interviews revealed that the facility's shower aide was frequently reassigned to floor duties due to staff shortages, resulting in residents missing scheduled showers. Documentation showed that some residents went weeks without a shower, with no records of refusals or alternative care being provided. For example, one resident received only a handful of showers over a three-month period, with gaps of up to 38 days between showers. The facility did not assign a replacement shower aide during the regular aide's absence, and therapy staff only provided showers to a limited number of residents during this time. Staff interviews confirmed that low staffing levels led to missed showers and delays in care. The Director of Nursing acknowledged that no replacement was scheduled for the shower aide during absences, and that therapy staff only assisted with showers for residents already receiving therapy. Group interviews with residents further corroborated that many did not receive showers for extended periods, particularly when the shower aide was on vacation. These failures resulted in residents experiencing feelings of frustration, helplessness, and anger, as well as observable declines in personal hygiene.