Failure to Provide Adequate Nursing Staff Resulting in Missed Care and Incomplete Treatments
Penalty
Summary
Facility staff failed to provide adequate nursing staff each day to meet the needs of all residents, resulting in deficiencies in care for six residents. One resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia was observed to be totally dependent on staff for activities of daily living, including incontinence care. The resident was documented as always incontinent and required two staff members for transfers and care. Despite care plan interventions specifying incontinence checks every two hours and as needed, the resident was observed seated in the same location throughout the day, and when incontinence care was finally provided, the resident's brief, clothing, and wheelchair pad were found to be saturated and wet. Staff interviews revealed that CNAs were responsible for high numbers of residents, with one CNA stating she had 16 residents that day, which was fewer than usual, and that she could not complete her work without stopping due to lack of available assistance for two-person care tasks. Additionally, for five other residents, an LPN documented being unable to complete provider orders due to increased patient load. The clinical records for these residents included notes stating that certain treatments, such as wound care and dressing changes, were not completed because of the nurse's workload. The LPN did not specify which tasks were left incomplete in some cases, and the documentation was entered as a medication administration note. The LPN was responsible for 28 residents during the shift, and a review of the staffing schedule confirmed that this was typical staffing for the unit, with two nurses and five CNAs assigned to 56 residents. The facility's staffing coordinator confirmed the usual staffing patterns and acknowledged the workload assigned to staff. The issue of incomplete care and documentation due to staffing levels was discussed with facility leadership, including the administrator, director of nursing, and regional clinical staff. No additional information or clarification regarding the incidents was provided to the survey team prior to the exit conference.