Failure to Provide Sufficient Nursing Staff Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on the A and B hallways, which are secured units. Multiple incidents of resident-to-resident abuse occurred, including physical and sexual abuse, as a result of inadequate staffing. Staff interviews and record reviews revealed that there were often only one or two CNAs assigned to halls with residents who had significant behavioral and cognitive impairments, including dementia, psychotic disorders, and histories of aggression or wandering. Staff frequently worked extended shifts, sometimes up to 24 hours, due to call-ins and staffing shortages, further compromising resident supervision and care. Several residents with severe cognitive impairments and behavioral issues were involved in altercations that resulted in injuries and emotional distress. For example, one resident with Alzheimer's disease and a history of psychotic disorder was pushed by another resident, resulting in a fracture. Other incidents included residents being hit or slapped by peers, and one case of sexual abuse that led to a resident being hospitalized. Care plans for these residents indicated the need for supervision, structured activities, and interventions to manage wandering and aggressive behaviors, but the lack of adequate staffing prevented consistent implementation of these interventions. Staff and management interviews confirmed ongoing staffing challenges, with reports of staff working excessive hours and being unable to provide adequate supervision or quality care. Payroll records corroborated that some CNAs worked nearly 24-hour shifts. The facility's own assessment acknowledged that staffing should be based on resident acuity and census, but the actual staffing levels did not meet these needs, especially during periods of increased resident behaviors and acuity. The deficiency resulted in multiple instances where residents were not protected from abuse or harm due to insufficient staff presence and supervision.