Failure to Provide Timely ADL and Transfer Assistance Due to Staffing Shortage
Penalty
Summary
A deficiency occurred when a resident with diagnoses including breast cancer and congestive heart failure, who was cognitively intact and required two-person assistance for bed mobility and transfers, was not provided timely care according to her preferences and care plan. The resident preferred to go to bed between 4:30 PM and 5:00 PM, but on the evening in question, was not assisted to bed until approximately 9:00 PM. During this period, the resident remained in her wheelchair, resulting in pain in her legs and being soaked in urine by the time she was finally transferred to bed and changed. The delay was attributed to a staffing shortage, with only one CNA working on the floor for approximately four hours, responsible for 20 residents, several of whom required two-person assistance. Multiple staff interviews confirmed the staffing shortage and the resulting delay in care. The resident's grievance and statements from staff, including the RN, CNA, Resident Care Manager/LPN, and DNS, all acknowledged that the resident's needs and preferences were not met due to inadequate staffing. The incident was verified by the former administrator, who confirmed that the delay in care was a result of the staffing failure on that evening.