Failure to Provide Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in multiple incidents where residents did not receive timely, person-centered care and supervision. On a specific shift, three residents experienced falls within one hour, including a resident with a history of stroke and dementia who attempted to transfer herself and fell, a resident with severe cognitive impairment who fell over equipment and sustained lacerations requiring hospital treatment, and another resident with dementia and a history of elopement who fell in a shower room while on a 15-minute observation schedule. Staffing records for that shift showed that the number of nurse aides and LPNs scheduled was insufficient for the resident census and acuity, with some staff required to provide one-to-one supervision, further reducing available personnel for other residents. Additional documentation and interviews revealed that residents who were totally dependent on staff for activities of daily living, such as toileting, bed mobility, and transfers, experienced significant delays in care. One resident reported waiting over an hour for call bell response, resulting in incontinence and soiled bedding, particularly during the second and third shifts. Another resident, who enjoyed participating in facility activities, stated he was unable to attend due to a lack of staff to assist him out of bed, and also reported missed showers. Review of shower logs confirmed that most scheduled showers were not provided, and there was no documentation that residents declined or preferred alternative care. Staff interviews and review of staffing schedules confirmed that the facility did not meet minimum nurse aide and LPN staffing ratios on multiple dates, nor did it consistently provide the required 3.2 hours of general nursing care per resident per day as mandated by state regulations. The facility's own policies required additional staff for residents on one-to-one supervision, but records showed that this was not consistently implemented, and staff were expected to provide both one-to-one monitoring and care for the rest of the unit. These deficiencies were confirmed by the Director of Nursing and Nursing Home Administrator, who were unable to provide evidence that staffing levels met regulatory requirements.