Failure to Provide Adequate Nursing Staff for Resident Supervision and Care
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the individualized care and supervision needs of residents, as required by their acuity and level of supervision (LOS) designations. Multiple residents with severe cognitive impairments, intellectual disabilities, and communication disorders were observed not receiving timely assistance with essential activities such as eating and toileting. Staff interviews and direct observations revealed that residents who required staff to anticipate their needs, one-to-one supervision, or close monitoring were left unattended or had to wait extended periods for care due to insufficient staffing. Specific incidents included residents who were dependent on staff for eating being left without meals or waiting long periods before being assisted, as staff were occupied with other residents or on break. In one instance, a resident with PICA and a need for close supervision was able to access and consume non-food items from the refrigerator while staff were assisting others. Another resident, who required staff to be present during toileting, was left unsupervised, resulting in privacy concerns and incomplete hygiene. Staff reported that when short-staffed, they had to prioritize care, leaving some residents without the required supervision or assistance, and that even with normal staffing, there were not enough staff to meet all residents' needs simultaneously during mealtimes. The facility's staffing challenges were compounded by a significant number of nursing assistants and a registered nurse being out due to on-the-job injuries, particularly from cottages with residents exhibiting severe combative behaviors. This led to staff being reassigned from other areas, further reducing available personnel and impacting the ability to provide care as outlined in residents' care plans and LOS requirements. The Director of Nursing confirmed that staffing was based on the overall needs of each cottage rather than the specific care levels required by individual residents, and acknowledged unaddressed changes in supervision needs for some residents.