Failure to Provide Sufficient Nursing Staff and Consistent Resident Care
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. Residents experienced delays in receiving assistance, such as one resident who became incontinent after waiting too long for help, leading to embarrassment. Other residents did not receive adequate assistance with activities of daily living (ADLs), including grooming, nail care, and transfers, as observed by unshaven faces, long and dirty fingernails, and soiled clothing. Staff interviews revealed that restorative nursing programs (RNPs) lacked clear goals and were inconsistently implemented, with some staff making modifications without licensed nurse or therapist direction. Residents with mobility and skin integrity needs were not consistently monitored or provided with appropriate care. For example, one resident with hand contractures was not provided with a splint or hand roll, and another had skin tears with dried blood and no dressings in place, which the Director of Nursing Services was unaware of. Pressure injuries were not properly monitored or documented, as shown by missing daily skin assessments for a resident with a pressure-related blister, despite orders for regular monitoring. Multiple residents experienced falls and injuries due to inadequate supervision, including unwitnessed falls resulting in lacerations, head trauma, and fractures when staff were unavailable to assist. The facility's grievance logbook and resident council interviews documented ongoing concerns about insufficient staffing and long call light wait times, with no resolution. Staff interviews confirmed a lack of awareness regarding required RN coverage and reliance on agency staff due to turnover and shortages. These deficiencies were cited under multiple federal tags, including resident rights, quality of care, accident prevention, and pressure injury prevention, and represent a repeat citation from a previous statement of deficiencies.