Insufficient Staffing Leads to Delayed Meals and Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents on the A unit, resulting in delayed meal service and untimely incontinence care for all 18 residents on the unit. Observations and interviews revealed that only one LPN and one CNA were assigned to the unit, which led to significant delays in serving breakfast trays, with the last tray being served nearly two hours after arrival. Multiple residents reported that their food was consistently cold, and staff confirmed that they did not have enough help to serve meals promptly or reheat food as needed. In addition to meal delays, incontinence care was not provided in a timely manner. Three residents reviewed for incontinence care had not been checked or changed until late in the morning, with one resident not receiving care until after 10:25 A.M. and another not being changed until after 11:00 A.M. Observations showed that residents' briefs were saturated with urine, bedding was wet, and one resident had red and discolored buttocks. Staff interviews confirmed that rounds for incontinence care were significantly delayed due to insufficient staffing, and that nail and personal hygiene care were also neglected. Residents and staff consistently reported that call lights were not answered promptly, and that assistance with personal care and meals was delayed. The facility's own policies required more frequent incontinence checks and timely meal service, but these were not followed due to inadequate staffing levels. The deficiency affected all residents on the A unit, as confirmed by the facility census and staff interviews.