Failure to Provide Sufficient Nursing Staff Resulting in Missed Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple deficiencies in care. Staff and family interviews, as well as direct observations, revealed that residents were left unattended for extended periods, did not receive timely assistance with activities of daily living (ADLs), and were not consistently offered toileting or position changes. For example, one resident was left in the same pajamas for several days, was not checked on after returning from the hospital, and did not receive assistance with toileting or morning care until prompted by family. Staff reported being responsible for up to 30 residents at a time, leading to delays in care, missed check and changes, and incomplete ADL support. Documentation showed that on several days, staffing levels were below the facility's own assessment and schedule, with shifts missing both licensed and nursing assistant hours. Specific residents experienced lapses in care, such as not receiving scheduled nail care, being left in soiled briefs for extended periods, and not being repositioned or toileted according to their care plans. One resident's brief was found to have the same staff initials from the previous day, indicating it had not been changed overnight, and staff confirmed that short staffing made it impossible to complete all required checks and changes. Another resident did not receive catheter care or morning hygiene due to staff being unable to complete all tasks, and care plans were found to be incomplete or missing essential information. Staff interviews confirmed that these lapses were directly related to inadequate staffing and high resident-to-staff ratios. Additional deficiencies included failure to respond to residents' food preferences and requests, as staff did not check for available food options or offer seconds, despite facility policy allowing for it. During medication administration, a resident was left unsupervised during a nebulizer treatment, contrary to care plan instructions, and was not assessed for self-administration. The nurse responsible stated she was too busy to remain with the resident or return promptly, and did not complete required post-treatment assessments. These events were corroborated by family and staff interviews, as well as direct observation, and were attributed to insufficient staffing and high workload.