Failure to Provide Sufficient Nursing Staff and Competent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of its residents, resulting in multiple instances where residents did not receive necessary activities of daily living (ADL) care and nursing services. Several residents reported being left in wet briefs overnight, not being checked or changed as required, and not receiving timely toileting assistance. In one case, a resident was left on the toilet for an extended period and had to return to bed without assistance. Another resident reported being left in bed naked and soiled with urine and feces overnight. These incidents were corroborated by interviews with residents and staff, as well as facility-reported incidents and grievances. Staff interviews revealed that the facility relied heavily on travel and agency staff, many of whom received little to no orientation or training specific to the facility. Staff reported that orientation for agency staff only occurred if a particular staff member was present, and no skills checklists were completed at the facility for these staff members. Agency staff themselves confirmed they had to learn the facility's routines and resident needs on their own, which hindered their ability to provide appropriate care. Additionally, staff reported frequent call-offs, particularly on nights and weekends, which led to inadequate staffing levels and long call light response times. Management rarely assisted by coming in to help cover shifts, further exacerbating the staffing shortages. Documentation reviews showed that a significant number of residents required two-person assistance for transfers and frequent checks and changes, which was difficult to accomplish with the available staff. On certain shifts, only one nurse was present for all LTC residents, and only three CNAs were available for five units, making it impossible to meet all residents' needs. The lack of staff also contributed to falsification of records, as one staff member completed required documentation from home rather than on-site. Multiple state survey agency incident reports confirmed that resident care was not being completed as required, and grievances were received regarding the lack of care provided.