Failure to Provide Adequate Staffing Resulting in Missed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents on multiple occasions, as evidenced by direct care staff daily reports, resident and staff interviews, and documentation reviews. On several dates, the number of Certified Nursing Assistants (CNAs) scheduled for both day and evening shifts was below the minimum required by Oregon state staffing ratios for the facility's census. This resulted in residents not receiving scheduled showers, delays in being put to bed, and missed oral care. Staff and residents consistently reported that management did not assist on the floor during shortages, and CNAs often skipped breaks or stayed late to complete tasks. Specific residents with diagnoses such as dementia, stroke, and cancer, who required assistance with activities of daily living (ADLs) like bathing, did not receive scheduled showers on the days when staffing was insufficient. Documentation was either missing or inaccurately indicated that residents refused care when, in fact, staff did not have time to provide it. Multiple staff members, including CNAs, LPNs, and the social service director, confirmed that showers and other care tasks were missed due to inadequate staffing, and that efforts to obtain agency staff were unsuccessful. The administrator and other management staff acknowledged ongoing staffing issues, confirming that resident needs were not met on the identified dates due to being short-staffed. The facility continued to admit new residents despite not having enough CNAs to provide required care, and staff reported that shortages were a frequent and unresolved problem. Residents expressed dissatisfaction with missed care, and staff described having to prioritize basic needs over other required tasks when working short.