Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in delayed care for a resident who was dependent on staff for toileting and transfers. The resident, who had multiple diagnoses including type 2 diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation, was frequently incontinent of bladder and bowel and required substantial assistance with daily activities. On the day in question, the resident activated the call light and waited over an hour for assistance. Although a nurse and a nurse aide entered the room after approximately 30 minutes, the resident had already experienced an incontinence episode and expressed frustration and embarrassment about the situation, noting concerns about her sensitive skin. Staff interviews confirmed that only one RN and one CNA were on duty at the time, and both acknowledged the facility was short staffed. The CNA reported being aware of the resident's accident but stated she needed to prioritize preparing breakfast for other residents before providing assistance. Another CNA confirmed being called in later due to staffing shortages. These observations and interviews demonstrate that the facility did not have sufficient nursing staff on duty to provide timely care and services, directly impacting the resident's dignity and comfort.