Failure to Provide Sufficient Nursing Staff for Resident Supervision
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of several residents, resulting in multiple incidents involving inadequate supervision and resident safety concerns. For one resident with severe cognitive impairment and a history of bipolar disorder and dementia, staff did not provide adequate supervision to prevent the resident from playing with and ingesting fecal material. The care plan did not address these behaviors, and there was no documentation of interventions or supervision strategies to prevent recurrence. Staff interviews confirmed that insufficient staffing, particularly on weekends, made it impossible to provide the necessary supervision for this resident. Another resident with aggressive behaviors was not provided with adequate supervision following an incident where the resident grabbed another resident by the shirt collar. Despite ongoing behavioral issues, including physical altercations and threats toward other residents and visitors, interventions such as room changes and one-on-one supervision were delayed and not implemented until after further incidents occurred. Staff interviews indicated that there were not enough staff to monitor residents effectively, especially those with a history of aggression, and that supervision was inconsistent and insufficient to prevent further incidents. A third resident was involved in multiple resident-to-resident altercations, including slapping, hitting, and entering other residents' rooms and beds. Documentation showed repeated incidents over several months, with staff unable to provide adequate supervision due to insufficient staffing levels. Staff interviews consistently reported that low staffing, particularly during high census periods and weekends, resulted in larger assignments for each CNA and less time to supervise residents, making it difficult to prevent such incidents. The facility's own policy requires sufficient numbers of staff to provide care and services in accordance with resident care plans, but this standard was not met.