Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of a resident who required extensive to total assistance with activities of daily living (ADLs), including toilet hygiene and eating. The resident, who had diagnoses such as dementia, contractures, dysphagia, aphasia, and a stage 4 pressure ulcer, was dependent on staff for all ADLs and was always incontinent. On one occasion, the resident's lunch tray remained untouched for several hours, and staff interviews confirmed that the resident had not been offered or assisted with lunch due to short staffing. The nurse aide responsible for the resident stated she was unable to provide timely assistance because she was assigned too many residents and did not ask for help as all staff were busy. Further documentation revealed that the resident was found saturated in urine and still in night clothes late in the day, with soiled linens and no evidence of having been cleansed or repositioned. The wound nurse who discovered this reported the incident, and the resident's roommate confirmed that care had not been provided throughout the day. Staff interviews indicated that nurse aides were frequently assigned to care for 20 to 40 residents per shift, making it difficult to complete essential care tasks such as bathing, feeding, and incontinence care in a timely manner. Multiple staff members, including nurse aides and unit managers, acknowledged that chronic short staffing led to delays in providing care, with some tasks being missed or only partially completed. The direct care staff reported that it was impossible to complete all required care for their assigned residents, especially when there were call outs and no additional help available. These staffing shortages directly resulted in the resident not receiving necessary assistance with eating and incontinence care.