Insufficient Nursing Staff Resulting in Missed Care and Delayed Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by direct care staff hours falling below the required levels on multiple days. On specific dates, the number of direct care staff hours worked was significantly less than what was needed based on the facility's PPD budget and resident census. This shortfall resulted in inadequate care for residents, particularly in areas such as hygiene and timely response to call lights. Multiple residents with significant care needs, including severe cognitive impairment, incontinence, and mobility limitations, did not receive scheduled showers or timely assistance with hygiene. Documentation showed that several residents missed their preferred shower days repeatedly throughout the month, and interviews with residents and their families confirmed that showers were often skipped due to short staffing. Residents reported having to wait extended periods for assistance with soiled briefs, and some were observed to be in dirty briefs or in rooms with foul odors. Family members and residents consistently stated that staff cited short staffing as the reason for missed care. Staff interviews corroborated these findings, with CNAs reporting that it was nearly impossible to complete all required tasks, including showers and answering call lights, due to insufficient staffing levels. The ADON acknowledged that three CNAs were not enough to meet resident needs, especially during mealtimes. Resident Council meeting minutes further documented ongoing concerns about inadequate staffing, missed showers, and delayed call light responses. The facility's own assessment tool indicated that staffing assignments were based on acuity and needs, but actual staffing did not meet these requirements on the reviewed days.