Insufficient Staffing Resulting in Unmet Resident Care Needs and Increased Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across three of four halls, resulting in unmet care needs and increased risk of falls. Review of facility records showed that a significant percentage of residents required assistance with activities of daily living, such as bathing, dressing, transferring, and toileting. Despite policies stating that staffing levels were reviewed daily and adjusted as needed, incident logs revealed a high number of resident falls over several months. Interviews with staff indicated that CNAs were often responsible for caring for up to 15 residents at a time, making it difficult to complete necessary care tasks, especially on weekends when staffing was lower. Staff also reported having to stay late to finish tasks and being frequently asked to cover open shifts. Observations and interviews with residents further highlighted the impact of insufficient staffing. One resident, who was dependent on two staff for transfers and had recently been diagnosed with pneumonia, reported not receiving scheduled showers, not being out of bed for six days, and not having their teeth brushed. Another resident stated they had not had a shower for at least two weeks and had not had their hair washed in about a month. Staff interviews confirmed that administrative nursing staff were counted in the nursing hours per patient day (PPD), but these staff were not always available on weekends. The deficiency was cited under WAC 388-97-1080 (1) and 1090 (1).