Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident as required by its own Facility Assessment Staffing Plan. Review of nurse staffing schedules revealed that the facility did not meet its minimum staffing requirements on numerous days, including specific dates in April and May, nearly the entire month of December, most weekends from January through March, and multiple days in May and June. The staffing shortfalls were confirmed by the Staffing Coordinator, who cited frequent callouts, vacations, and a reliance on per diem staff who worked irregularly. The Administrator and Assistant Administrator acknowledged awareness of the low staffing levels and stated that hiring new staff was challenging, with little use of incentives or bonuses to fill shifts. Residents reported significant delays and omissions in care due to inadequate staffing. Multiple residents stated they did not receive showers as scheduled, sometimes going weeks without one, and experienced long waits for assistance with toileting, dressing, and transfers out of bed. One resident described being left in a soiled brief for hours, while another expressed fear of having a bowel movement due to the likelihood of remaining soiled for extended periods. Observations confirmed that some residents remained in bed late into the day and that family members had to assist with feeding due to staff shortages. Resident Council members also reported excessive wait times for care, with one noting that a roommate waited three hours for a colostomy bag to be emptied and another waiting six hours for a brief change. Staff interviews corroborated the residents' accounts, with Certified Nurse Aides and nurses stating that they were often the only staff member on a unit, making it impossible to meet all residents' care needs in a timely manner. Staff reported that nurses were unable to assist with direct care due to their medication and documentation responsibilities, and that the facility did not offer extra pay or bonuses to incentivize staff to work additional shifts. The Director of Nursing and other leaders confirmed ongoing difficulties in recruiting and retaining staff, and the Assistant Administrator ultimately acknowledged that the Facility Assessment Staffing Plan itself did not document a sufficient number of staff to provide adequate care to residents.