Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the care needs of residents, resulting in multiple instances where residents did not receive timely assistance with incontinence care, prevention of pressure wounds, and response to call lights. One resident, recently admitted with a pressure wound and urinary tract infection, reported waiting hours for incontinence care, sometimes needing to call a family member for help in contacting staff. Upon observation, dried feces and skin redness were noted, and the resident had not received incontinence care or repositioning for several hours during the shift. Staff confirmed that care was delayed and that the wound nurse, not the assigned CNA, provided the necessary care during a dressing change. Another resident was observed repeatedly calling for help, with the call light on and staff walking past without responding. The resident reported nausea and discomfort from knee braces, and stated that requests for medication and assistance were not addressed for several hours. Staff interviews confirmed that the resident's complaints were reported to the nurse multiple times, but the nurse had not administered the ordered medication. Facility policy requires prompt response to call lights, but this was not followed. Additional residents and family members reported similar issues, including long waits for incontinence care, missed showers, and insufficient staff to meet scheduled care needs. Staff interviews revealed that CNAs were assigned to care for up to 20 residents at a time, making it difficult to complete all required tasks. The facility's staffing schedules showed that, on at least 22 shifts, the number of nurses or CNAs was below the facility's own requirements. The administrator confirmed there was no formal staffing policy in place.