Failure to Provide Adequate Nursing and Housekeeping Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by multiple documented instances of insufficient nurse aide (NA) coverage and delayed response times to call lights. Review of staffing records showed that, over a period of several weeks, the facility did not meet its own predetermined NA staffing levels for its census, with some days having as few as two NAs on the floor during the day shift. This staffing shortage was confirmed by both staff interviews and the Director of Nursing, who acknowledged that the facility had not met required NA staffing levels as the census increased from 27 to 35 residents. Residents with significant care needs, including those with cognitive impairments, limited mobility, and self-care deficits, experienced delays in receiving assistance with activities of daily living (ADLs) such as bathing, toileting, and hygiene. Documentation revealed that one resident, who required assistance with ambulation and bathing, did not receive baths at the frequency specified in their care plan, with gaps of up to 14 days between baths. Multiple residents had call light response times that exceeded the facility's standard of 10 minutes, with some instances of call lights going unanswered for up to 53 minutes. These delays were noted repeatedly for several residents, particularly during periods of low staffing. In addition to nursing staff shortages, the facility also failed to maintain daily cleaning of resident rooms as required. The only housekeeping staff member was frequently reassigned to work as a NA, resulting in missed cleaning duties. Interviews with environmental services and maintenance staff confirmed that there was no clear schedule or record of which rooms were cleaned during certain periods, and that maintenance and laundry staff were sometimes tasked with cleaning in the absence of dedicated housekeeping personnel. These combined staffing and housekeeping deficiencies had the potential to affect all residents in the facility.