Failure to Accommodate Resident Shower Preferences Due to Low Weekend Staffing
Penalty
Summary
The facility failed to accommodate resident preferences for showers on one of its units due to low weekend staffing. Payroll Based Journal (PBJ) records and weekend schedules for March 2025 showed that only two certified nursing assistants (CNAs) were scheduled for a unit with a census of 59 residents, instead of the usual four to five CNAs per shift. Staff interviews confirmed that, as a result, showers were not provided to residents on those days. Instead, CNAs prioritized essential care, providing hygiene and shortened bed baths, and ensured residents were fed and kept safe with assistance from other nursing staff. The Director of Nursing (DON) acknowledged the staffing shortage and the absence of a staff coordinator at the time. Both the DON and a unit manager LPN confirmed that the goal is to have four CNAs per shift, but this was not achieved during the weekend in question. Staff reported that when such shortages occur, non-essential care such as showers is deprioritized. No additional information was provided by the facility prior to the exit conference.