Failure to Provide Adequate Staffing Results in Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents in the Rosewood residential area, which included three units. On multiple occasions, there was only one nurse covering all three units during the night shift, with only one nursing assistant assigned to each of the front and middle units, and no nursing assistant assigned to the back unit. This resulted in periods where no staff were present on the back unit, leaving residents without timely assistance for incontinence care, repositioning, or other needs. Observations documented strong odors of urine, unanswered call lights, and residents waiting extended periods for help, including one resident who had to get up from a recliner and walk around the bed to access the call light, and another resident who was left in a soiled brief for several hours, resulting in skin irritation. Staff interviews confirmed the lack of adequate coverage, with the nurse on duty having to perform both nursing and nursing assistant duties for the back unit, and nursing assistants reporting difficulty completing care due to being alone and unable to leave their assigned units. Residents and their private aides also reported frequent delays in receiving assistance, with some residents not being able to get up for breakfast or to the dining room as scheduled, and others missing meals or not receiving requested beverages. The lack of staff also led to situations where mechanical lifts and two-person assist tasks were either delayed or performed with only one staff member, contrary to care requirements. Review of facility records showed that the majority of residents in these units required moderate to total assistance with activities of daily living, incontinence care, and mechanical lifts. Incident logs indicated a rising trend in resident falls over recent months. Staffing data revealed that while the facility met the minimum required direct care hours, actual staff assignments left units inadequately covered, especially on weekends and night shifts. Facility policies required regular incontinence care and call light accessibility, but these were not consistently followed due to insufficient staffing.