Failure to Provide Adequate Staffing for Resident Transfers and ADLs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly those requiring assistance with mechanical lifts for transfers and activities of daily living (ADLs). Multiple residents who required two-person assistance for transfers with Hoyer or sit-to-stand lifts were often transferred by a single staff member, contrary to facility policy and individual care plans. This practice was confirmed through staff and resident interviews, as well as direct observation, and was attributed to ongoing staffing shortages. In some cases, staff who were minors and not permitted to operate mechanical lifts were scheduled, further exacerbating the issue. Residents dependent on staff for transfers, such as those with severe cognitive impairment or physical limitations, were left waiting for extended periods for assistance or were transferred unsafely. Documentation and interviews revealed that residents frequently did not receive scheduled showers or timely toileting assistance, with some residents reporting going up to two weeks without bathing. Staff reported working extended hours and being unable to provide adequate care due to insufficient staffing, leading to delays in meeting residents' basic hygiene and mobility needs. Observations showed residents left unattended for long periods, requesting help to go to bed or to the toilet, and not receiving assistance in a timely manner. Staff confirmed that due to the lack of available personnel, they often had to perform transfers alone, even when two-person assistance was required for safety. The deficiency affected both residents with cognitive impairment and those who were cognitively intact but physically dependent, resulting in unmet care needs and deviations from established care plans.