Insufficient Staffing Resulting in Missed Resident Care and Hygiene
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the care needs of residents, as required by the facility assessment and federal regulations. Observations and interviews revealed that multiple residents did not receive adequate personal hygiene, including regular showers, grooming, and oral care. Several residents were observed with long facial hair, disheveled or greasy hair, and long fingernails, indicating a lack of assistance with personal care. Residents reported going weeks without showers and feeling unclean, while staff confirmed that showers and hygiene tasks were often missed due to insufficient staffing. Staff interviews consistently described being assigned to care for large numbers of residents, sometimes up to 28 per aide, including many who required mechanical lifts for transfers. Staff reported that they often had to leave their assigned halls unattended to find assistance for lift transfers, further reducing the time available for other care tasks. During mealtimes, there were not enough aides to assist residents, leading to situations where one staff member was responsible for feeding multiple residents. Non-nursing staff, such as the housekeeping supervisor and social service director, were observed assisting with resident care during surveyor visits, but staff indicated this was not typical practice and only occurred due to the presence of surveyors. The facility's own assessment identified the need to adjust staffing based on resident acuity, census, and care needs, including the high number of residents requiring mechanical lifts. Despite this, staff and residents reported that the actual staffing levels were inadequate to meet these needs. The Director of Nursing and Administrator acknowledged that showers were not completed as scheduled and that complaints about staffing were received from residents and families. The deficiency affected at least five sampled residents and had the potential to impact all residents in the facility.