Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, as required by their own facility assessment and federal regulations. Staffing schedules for the second floor consistently fell below the minimum number of Certified Nursing Assistants (CNAs) needed, with multiple days showing only four to seven CNAs present when at least eight were required. The Human Resource Manager confirmed that the facility did not use agency staff and relied on an outsourced scheduling company, resulting in persistent understaffing. The Administrator acknowledged that staffing levels did not meet the facility's own assessment standards for the entire review period. Direct observations and interviews revealed that residents experienced significant delays in receiving care, including long waits for assistance, missed showers, and inadequate incontinence care. Several residents reported not receiving showers for weeks, waiting up to 1.5 to 2 hours for call lights to be answered, and not having their needs addressed in a timely manner. Staff interviews corroborated these concerns, with CNAs and LPNs stating that there were not enough staff to meet resident needs, leading to missed care and incomplete documentation. Specific resident cases highlighted the impact of insufficient staffing. One resident with chronic conditions and limited mobility developed a sacrococcygeal wound, with observations showing prolonged periods without incontinence care or repositioning, resulting in saturated briefs, foul odor, and open wounds. Another resident with a tracheostomy was observed with thick mucus accumulation and a dusty suction machine, with staff unable to confirm when suctioning last occurred. Multiple records confirmed that scheduled showers were not completed for several residents, and staff consistently reported that the number of CNAs on duty was inadequate to provide necessary care.