Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of multiple residents, as evidenced by observations, interviews, and record reviews. Several residents with significant medical conditions, such as acute respiratory failure, dementia, chronic kidney disease, quadriplegia, and severe mobility impairments, did not receive timely assistance with activities of daily living (ADLs) including bathing, toileting, transfers, and medication administration. Documentation showed missed or delayed showers and bed baths, with some residents receiving only one bath per week despite being scheduled for more frequent care. There were also instances where residents waited extended periods for assistance with toileting and transfers, and medication administration was delayed until late in the day or night. Residents and their representatives reported concerns about inadequate staffing, particularly on weekends and holidays, leading to delays in care and unmet needs. Some residents described waiting several hours for call lights to be answered, not being assisted out of bed as requested, and not receiving scheduled showers or baths. Family members corroborated these concerns, noting that they or other families stayed late to ensure care was provided, and that medication administration was sometimes delayed until a DON intervened. Staff interviews confirmed frequent short staffing, with only one CNA per hall instead of the scheduled two, and difficulties in providing two-person assist for residents requiring mechanical lifts. Staff also reported confusion about shower assignments, lack of training, and unclear supervisory structures. Documentation in the facility's electronic record system often lacked entries for required ADL care on multiple days, and there were no documented refusals from residents to explain these omissions. Staff consistently reported that administration was aware of the staffing shortages but only responded that they were working on the issue, with no resolution provided. The lack of sufficient staff directly resulted in delayed or missed care for residents, as confirmed by both staff and resident interviews, as well as gaps in care documentation.