Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews, record reviews, and staff schedules. Several residents with varying medical conditions, including dementia, diabetes, post-traumatic stress disorder, asthma, chronic pain, major depressive syndrome, spinal stenosis, chronic obstructive pulmonary disease, stroke, and pressure ulcers, did not consistently receive scheduled showers or timely assistance with activities of daily living (ADLs). Documentation showed that residents often missed scheduled bathing opportunities, and staff did not always reattempt or document refusals as required by care plans. Residents reported long waits for call light responses, late medication administration, and staff rushing through care tasks. Some residents specifically noted that showers did not occur on their preferred or scheduled days, and that staff did not spend adequate time with them. Observations included residents appearing disheveled and in poor hygiene, with visible sores and scabs. Resident council minutes and grievance forms further documented ongoing concerns about short staffing, inconsistent assignment of nursing assistants, missed showers, and lack of communication regarding medication needs. Staff interviews confirmed that staffing shortages were frequent, with bath aides (BAs) often being reassigned to cover other shifts, leaving nursing assistants (NAs) responsible for both floor duties and showers. Staff described feeling overwhelmed and unable to complete all required care, particularly when high-acuity residents were present or during periods of increased absenteeism. Leadership acknowledged the ongoing issues with staffing and the impact on resident care, including missed showers and delayed medication passes.