Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide competent and sufficient nursing staff to meet the personal care needs of multiple residents, as evidenced by direct observations, interviews, and record reviews. Several residents did not receive timely assistance with activities of daily living (ADLs) such as dressing, personal hygiene, toileting, and bathing, as outlined in their care plans. For example, one cognitively intact resident reported waiting since early morning for assistance with getting up and having their brief changed, with staff repeatedly turning off the call light without providing care. Another resident, who was cognitively impaired, was observed multiple times lying in bed in soiled conditions, with a strong odor of urine in the room, and their call light on the floor. Staff assigned to these residents admitted to not having provided complete care due to time constraints and high workload. Additional residents were affected by missed showers and inadequate personal hygiene. One resident reported not receiving scheduled showers because staff stated they were short-staffed and did not have time. Staff confirmed that due to insufficient staffing, they were unable to complete showers and could only provide brief changes and respond to call lights. Another resident expressed frustration at not receiving oral care and having to wait hours for assistance, attributing these delays to staff being too busy. Staff interviews corroborated that the high resident-to-staff ratio prevented them from delivering all required care, especially when scheduled staff called out and replacements were not available. The Director of Nursing acknowledged that the expectation was for nursing assistants to provide comprehensive morning and evening care, including oral care, personal hygiene, and showers as scheduled. However, the DON also stated that when staffing was inadequate, care could be missed despite efforts to have management assist or call in additional staff. Documentation reviewed for the affected residents did not indicate that care was refused by the residents, further supporting that the deficiencies were due to insufficient staffing rather than resident choice.