Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents, resulting in delayed care and incomplete activities of daily living (ADLs). Multiple residents reported excessive wait times for staff response to call lights, with some waiting up to two hours, particularly during night shifts and shift changes. Several residents described incidents where they were left in soiled briefs or had to wait extended periods for assistance with toileting, leading to episodes of incontinence. Residents also reported missed showers, infrequent oral and hair care, and delays in receiving pain medication. Resident council interviews and meeting notes further documented ongoing concerns about inadequate staffing, delayed medication administration, and insufficient attention to personal care needs such as catheter care and timely showers. Residents expressed that agency staff were often unresponsive, did not perform required duties, and were sometimes disrespectful. Grievance logs corroborated these issues, with multiple complaints about slow call bell responses and lack of timely check and change care. Staff interviews confirmed that CNAs did not have enough time to complete all required assignments, often having to forgo non-mandatory but important aspects of care such as oral hygiene, nail care, and hair care. Staff reported that agency personnel frequently failed to provide adequate care, including not changing briefs or assisting with meals. The Director of Nursing acknowledged expectations for timely call bell response and completion of ADLs but was unaware of the extent of the issues reported by staff and residents.