Insufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents involving three residents. One resident, who was legally blind, had dementia, and was dependent on staff for personal and toileting hygiene, was found by a family member in the evening with her hair, gown, and bed soaked in urine, and her room had a strong odor. Documentation showed that incontinent care was only provided once earlier in the day, and staff assignments indicated fewer CNAs present than scheduled. Interviews with staff could not clarify the care provided during the shift in question. Another resident, who had hemiplegia, hemiparesis, and required a two-person assist with a mechanical lift for transfers, reported that he was unable to get out of bed for 24 hours due to insufficient staff. Staffing records confirmed that fewer CNAs were present than scheduled, and a nurse was working as a CNA. The resident stated that delays in getting out of bed occurred when the facility was short-staffed, and a CNA confirmed that staffing ratios made it difficult to meet residents' preferences for getting up. A third resident, who was dependent on staff for transfers and toileting hygiene, reported waiting more than two hours for assistance with incontinent care during the evening shift, leading him to remove his own brief to prevent skin breakdown. Resident council records and staff interviews indicated ongoing concerns about insufficient staff, particularly at night, with residents reporting infrequent care and long wait times. The facility's assessment did not include information on the level of staff needed to meet each resident's needs, and scheduling was based primarily on census and PPD, without clear consideration of resident acuity.