Insufficient Nursing Staff Resulting in Missed Care and Delayed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by staff and resident interviews, documentation review, and direct observations. Nurse aides and licensed nurses reported that staffing levels were inadequate, particularly on the second and third floors, resulting in residents not receiving routine care such as showers and timely assistance with activities of daily living. Staff described working twelve-hour shifts with only three aides for 37 residents, making it difficult to provide care that required two staff members, such as Hoyer lift transfers, and leading to residents waiting longer than appropriate for care. Three residents were specifically affected by the staffing shortage. One resident with high blood pressure, post-polio syndrome, and vitamin D deficiency reported not receiving scheduled showers and described an incident where an aide attempted a transfer without proper equipment or assistance, resulting in discomfort and feelings of disrespect. Documentation confirmed that this resident received only three showers in the past 30 days, with the last one occurring over two weeks prior to the interview. Another resident with end stage renal disease, heart failure, and high blood pressure stated they had not received a shower in over a month, despite a scheduled shower routine, and documentation showed only one shower in the past 30 days. A third resident with similar diagnoses also reported not receiving showers as scheduled, with records indicating only three showers in the same period. Interviews with registered nurses and the Director of Nursing confirmed the lack of sufficient staff to provide necessary care, with staff acknowledging that residents had to wait for assistance and that it was often difficult to find a second person for required two-person transfers. The Director of Nursing was unable to locate complete shower documentation for the affected residents and confirmed the facility's failure to provide adequate nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being for the residents involved.