Insufficient Staffing Leads to Missed ADL Care and Delayed Wound Treatment
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of residents, resulting in inadequate provision of activities of daily living (ADL) care, delayed and incomplete wound assessments, and insufficient medical treatment for pressure ulcers and diabetic care. Observations, record reviews, and interviews revealed that dependent residents did not consistently receive showers, and staff were frequently pulled from their assigned duties to cover staffing shortages, leading to missed care tasks. For example, shower team nursing assistants were reassigned to floor duties, resulting in multiple days when no showers were provided to residents. The facility also failed to obtain timely treatment orders and conduct routine assessments for residents with pressure ulcers. In several cases, pressure ulcers were identified but not promptly assessed or treated, leading to worsening conditions. One resident's pressure ulcer progressed to an unstageable wound with black eschar and foul odor due to delayed assessment and treatment. Another resident developed a stage 2 pressure ulcer that was not measured or reassessed after the initial treatment order expired, and no further treatment orders were obtained. Additionally, head-to-toe skin assessments were not completed accurately, failing to document the location, type, and measurements of wounds. Interviews with the Wound Nurse and administrative staff confirmed that staffing shortages significantly impacted the ability to provide consistent wound care and complete necessary documentation. The Wound Nurse reported being frequently reassigned to hall duties, making it difficult to monitor and treat wounds regularly. Administrative staff acknowledged that showers, wound treatments, and assessments were not being completed as required due to ongoing staffing challenges, including staff on leave and reduced availability.