Failure to Provide Sufficient Nursing Staff Resulting in Resident Harm and Missed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. Several residents were found with poor hygiene, such as long, dirty fingernails, soiled clothing, and unclean bedding. Staff reported being frequently mandated to work extended shifts, leading to burnout and an inability to complete all required care tasks. Certified Nurse Aides (CNAs) and an LPN described having to cut corners on resident care, including missing nail care, hygiene, and timely response to call lights, due to chronic understaffing and high rates of staff call-ins and turnover. One resident with a seizure disorder and severe cognitive impairment was observed in a disheveled state, with soiled clothing and untrimmed, dirty fingernails. Another resident, who was cognitively intact but fully dependent for toileting and bathing, reported waiting over an hour for call light responses and experiencing soiled bedding and skin. This resident also described refusing care at times because staff were rushed and unable to provide care in a respectful manner. Staff confirmed that these issues were due to insufficient staffing levels, which made it difficult to provide adequate supervision and assistance to all residents. A resident with Alzheimer's disease and swallowing difficulties was observed eating food from discarded trays and being given food inconsistent with her prescribed mechanical soft diet, without adequate staff supervision in the dining area. Another resident suffered a third-degree burn from hot coffee when a CNA, distracted by other resident needs and short staffing, failed to ensure the coffee was safe before serving it. Staff interviews consistently attributed these incidents to inadequate staffing, which resulted in missed care, lack of supervision, and direct harm to residents.