Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints, staff and resident interviews, and review of staffing documentation. Six out of nine complaints submitted to the Office of Health Care Quality alleged inadequate staffing, resulting in delayed or missed essential care such as timely cleaning after bowel movements, turning and repositioning, showers, and basic hygiene. Residents and their representatives reported waiting hours to be changed, being left soiled or wet, missing scheduled showers, and experiencing delays in being assisted after dialysis or for therapy appointments. Documentation confirmed that some residents did not receive scheduled showers, and one resident's physical therapy was delayed due to lack of available therapists. Front-line staff interviews consistently described high resident-to-staff ratios, with some staff responsible for 15 to 20 residents per shift. Staff reported being unable to complete all required care tasks, such as turning and repositioning every two hours, providing showers, and performing nail care. Staff also noted that management did not assist during short staffing, and that excessive charting requirements further limited the time available for direct resident care. Some staff described situations where only one aide was present for an entire unit, and new staff left after orientation due to overwhelming workloads. Review of staffing sheets from multiple days confirmed that units often operated with only two GNAs for 27 to 37 residents, resulting in ratios as high as 1:18 or 1:19. Additional documentation revealed medication administration issues when a nurse was required to cover a cart without proper training, leading to missed medication passes. Observations of staffing boards and further interviews with the DON confirmed ongoing concerns about inadequate staffing levels throughout the facility.