Failure to Maintain Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by state regulations and the facility's own assessment. Staffing reports for multiple days showed that both Licensed Practical Nurse (LPN) and Certified Nurse Aide (CNA) hours per resident per day were consistently below the mandated minimums. The facility assessment indicated the required staffing levels, but actual staffing fell short, with some shifts having only one aide responsible for up to 38 residents. The Director of Nursing and Administrator both acknowledged that the facility had not met minimum staffing levels for an extended period, and that the use of ancillary and agency staff was not sufficient to fill the gaps. Observations and interviews revealed that residents who required assistance with activities of daily living, such as eating and toileting, were not receiving timely or adequate care. Several residents with severe cognitive impairment and physical limitations were observed eating meals in their rooms without staff supervision or assistance, despite care plans indicating they required help. Residents were also observed in soiled incontinence briefs, struggling to access their meals, or unable to get out of bed for activities due to lack of staff. Staff interviews confirmed that showers were often missed, and that aides were unable to provide care to each resident more than once per shift. Multiple residents and family members reported long wait times for call lights to be answered, sometimes exceeding an hour, resulting in incontinence episodes and residents remaining in wet beds overnight. Some residents stated they no longer used their call lights because they did not expect a timely response. Staff consistently reported that the number of aides on duty was insufficient to meet residents' needs, particularly on weekends and night shifts. The deficiency was further corroborated by complaints submitted to regulatory agencies, which described residents left in soiled briefs for extended periods due to inadequate staffing.