Failure to Provide Sufficient Nursing Staff and Care Interventions
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of its residents, as determined by resident assessments and individual care plans. This deficiency was observed through multiple incidents, including inadequate assistance with positioning during tube feeding, insufficient staff to provide wound care and documentation, and lack of adequate supervision and staffing on the secured unit, particularly during mealtimes. These failures were identified for a significant number of residents, with specific examples including a resident who was left leaning over the armrest of a Geri-chair for approximately 1 hour and 30 minutes during tube feeding, resulting in aspiration pneumonia, and several residents who did not receive required wound care treatments or documentation on multiple occasions. Resident records revealed that individuals with complex medical needs, such as those with Alzheimer's disease, severe malnutrition, pressure ulcers, and significant cognitive and physical impairments, were not consistently provided with the necessary care and supervision. For example, one resident with a gastrostomy tube and severe ADL dependency was not properly positioned during tube feeding, leading to a hospital transfer for aspiration. Other residents with stage 3 and stage 4 pressure ulcers had multiple days where wound care treatments were not documented as administered, despite physician orders and care plan interventions requiring daily or scheduled treatments. Additionally, the facility did not ensure that the secured unit was adequately staffed to prevent accidents and provide supervision during critical times such as mealtimes. The lack of sufficient staff led to missed care interventions, incomplete documentation, and increased risk for resident safety. The survey identified an Immediate Jeopardy situation due to these failures, which was later removed, but the facility remained out of compliance due to ongoing gaps in staff education and policy adherence.