Failure to Provide Sufficient Nursing Staff Results in Missed Care and Resident Neglect
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple instances where residents did not receive required care. Several residents did not receive scheduled showers or bathing assistance as documented in their care plans and shower schedules. Staff interviews revealed that often only one aide was assigned to a unit, making it impossible to complete all required care tasks, including showers and hygiene. Documentation was missing or inaccurate, and some staff admitted to charting care that was not actually provided. Residents reported not receiving showers despite requesting them, and observations confirmed poor hygiene, such as oily and uncombed hair. Incontinence care was also not provided as required, with residents left in soiled briefs for extended periods. In one case, a resident was left in feces for at least 30 minutes, prompting friends to call the police and Adult Protective Services. Staff confirmed that due to staffing shortages, they had to triage care and prioritize based on urgency, resulting in delays or missed care. Another resident with an indwelling catheter was not changed or cleaned for an extended period, leading to a urinary tract infection and hospitalization. The resident reported calling 911 due to neglect, and hospital records confirmed the presence of infection and poor hygiene. Restorative care, such as passive range of motion exercises, was not completed as ordered for a resident with quadriplegia. Documentation showed that the required exercises were missed on multiple days, and staff interviews confirmed that care was not provided due to insufficient staffing. Residents and staff consistently reported that the lack of adequate staffing prevented them from meeting residents' needs, and the DON acknowledged being unable to follow up on missed care due to being overburdened with multiple roles.