Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient caregiver staff were available to meet the needs of residents who required assistance with repositioning, toileting, and incontinence care. One resident, who was dependent on staff for repositioning due to a full-length leg cast and other medical conditions, developed a Stage II pressure ulcer to her coccyx after admission. Documentation and interviews revealed that her care plan was incomplete, lacking specific interventions for her high risk of pressure ulcers, and that staff were not always able to provide the necessary repositioning and skin care. The resident's Braden Scale score indicated she was at risk, and her skin was already compromised on admission, but the care plan did not address her cast, wound vac, catheter, or specific assistance needs. Another resident, who relied on staff for toileting and incontinence care, reported that a CNA turned off her call light without providing assistance, resulting in an episode of incontinence and the resident remaining in wet garments overnight. The resident and her daughter both described multiple instances where timely assistance was not provided, and the daughter noted an increase in wet clothing over the past month. The facility did not have the capability to audit call light response times, and staffing records showed that on several overnight shifts, only one CNA and one nurse were available to care for up to 40 residents. Staff interviews confirmed that overnight staffing was often limited to one CNA and one nurse, with the CNA responsible for all resident rounds and call lights. Staff described difficulty meeting resident needs during these shifts, especially when caring for residents with high acuity or end-of-life needs. The facility's resource packet and facility assessment did not document current staffing levels or provide clear guidance on how to ensure adequate staffing to meet resident acuity and needs. These actions and inactions led to unmet care needs, including the development of a preventable pressure ulcer and unaddressed incontinence episodes.