Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the individualized needs of residents, as evidenced by clinical record review, staff interviews, and facility policy review. One resident with moderate cognitive impairment, requiring moderate assistance for bathing and partial assistance for personal hygiene, did not receive a bath or shower for a period of 17 days. Staff interviews revealed that certified nursing assistants (CNAs) and registered nurses (RNs) were unable to complete all required personal care tasks due to routine understaffing. Staff reported that these concerns had been brought to management multiple times without any observed improvement. Additional interviews with licensed practical nurses (LPNs), RNs, and CNAs indicated that wound care treatments and scheduled baths were often delayed or missed when medication aides were not available or when only one CNA was assigned to a hallway with approximately 25 residents, many of whom required two staff members for mechanical lift transfers. Staff also reported that, due to insufficient staffing, residents sometimes received meals in their rooms instead of the dining room, and feeding assistance was provided one at a time. The facility's assessment stated that staffing was based on resident acuity and that contingency plans existed for staff call-outs, but staff consistently reported that these measures were insufficient to address ongoing staffing shortages.