Insufficient Nursing Staff Resulting in Missed Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on one of its care units, resulting in missed and inconsistent bathing care for multiple residents. Documentation showed that residents who required assistance with showers did not consistently receive them as scheduled, with records lacking evidence that showers were offered, accepted, or refused on several occasions. Interviews with residents confirmed that showers were not provided according to their care plans or preferences, with some residents receiving showers only once every two weeks or less frequently than their care plans specified. One resident, who required assistance from two staff members, went 22 days without documented bathing after a scheduled shower, and another resident with frequent diarrhea did not receive the three showers per week as preferred. Staff interviews revealed that insufficient CNA staffing, particularly during night shifts, prevented the completion of scheduled showers, as staff had to prioritize other resident care needs such as answering call lights. CNAs reported that on some days, they could only provide one shower due to low staffing levels, despite the expectation to complete more. The DON acknowledged ongoing efforts to stabilize the staff schedule but confirmed that missed showers were sometimes due to staff shortages and resident staff preferences, which led to missed opportunities for care.