Failure to Provide Sufficient Nursing Staff and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple reports of delayed call bell responses, missed showers, and lack of fresh ice water. Facility policies require that call lights be answered within five minutes if possible, showers be provided per schedule or request, and appropriate care for activities of daily living (ADLs) such as bathing and hygiene. However, interviews with residents and review of resident council minutes over a six-month period revealed consistent complaints about slow call bell responses, infrequent passing of ice water, and missed showers, particularly when agency staff were present or on weekends. Specific residents reported waiting up to an hour for call bell responses, not receiving scheduled showers, and not having access to fresh ice water unless specifically requested. Documentation confirmed that some residents did not receive showers according to their schedules, and in some cases, residents went extended periods without bathing. One resident noted that the lack of hot water in a shower room was not addressed by using alternative shower rooms, resulting in missed showers and poor hygiene. Another resident, newly admitted, had not received a bath or shower since admission and complained of discomfort due to unwashed hair. Grievance logs and resident council minutes corroborated these issues, with repeated grievances about call bell response times, missed showers, and lack of fresh ice water. The Director of Nursing confirmed that residents are entitled to timely call bell responses, regular showers, and fresh ice water, but acknowledged that these needs were not consistently met. These findings demonstrate a failure to provide adequate nursing services and staffing to promote the physical and mental well-being of residents, as required by facility policy and state regulations.