Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of eight out of eleven residents, as evidenced by multiple resident interviews, observations, and documentation reviews. Residents reported long wait times for call light responses, delayed medication administration, and untimely assistance with activities of daily living such as getting in and out of bed. One resident described having to wait from early morning until late morning for assistance and reported being told by staff that they were not the only one needing help. Another resident stated that they had to call their family to get staff attention during the night. Observations included residents being malodorous, with one resident noted to have large amounts of a brown substance under their fingernails, and rooms with overpowering urine odors. Documentation showed significant gaps in incontinence care, with one resident not receiving documented care for over ten hours. Additional evidence from Resident Council meeting minutes and grievance reviews indicated ongoing concerns about insufficient staff to assist with changing soiled sheets and providing scheduled showers. Several residents reported not receiving showers on their scheduled days, with no refusals documented. One grievance detailed a resident remaining in bed without bathing assistance late into the morning. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary care to maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.