F0725

J

Failure to Reassign Staff After NA No-Show Leaves Entire Hall Without ADL Care

Pittsburgh, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs on the West Hall (rooms 209-A through 217-B), resulting in 12 residents not receiving required ADL care for an entire morning and into the afternoon. On the day of the survey, only two NAs were present on the second floor because the NA assigned to the West Hall did not report for work, and the assignment was not reallocated to other staff. Staff reported that management, including the administrator, DON, and supervisor, had been informed of the staffing shortage. Despite this, no NA coverage was arranged for the affected section, and nurses on the unit did not consistently assume ADL care responsibilities for the unassigned residents.

Surveyors observed that all 12 residents in rooms 209-A through 217-B remained in bed around midday with disheveled appearances and still in nightgowns. Multiple residents reported that no one had come in to clean them, change their briefs, assist them out of bed, or provide incontinence care since the overnight shift. One resident stated that only a nurse had come in to administer medications and that they had to seek out someone to request to see the nurse practitioner. Several residents with conditions such as diabetes, hemiplegia, cerebral infarction, heart failure, paraplegia, COPD, and other chronic illnesses reported being soiled with diarrhea or urine since early morning, with no brief changes or application of protective creams, and no assistance with bathing, showering, dressing, or repositioning.

Interviews with staff confirmed that no morning care, incontinence care, repositioning, or assistance out of bed had been provided to the residents in the unstaffed section. An LPN stated that when informed there was no third NA, the supervisor said nurses would need to help, but the LPN reported she could not assist with care and that no care had been done since the overnight shift. An RN on the unit stated that she had offered to help but that the LPN refused, and that residents had been left without care. NAs and nursing staff consistently acknowledged that the entire section had no NA coverage, that residents did not receive basic ADL services, and that this constituted neglect. At one point, surveyors observed the RN, LPN, and NA at the nurse’s station talking while residents in the affected section remained without care. The NHA and DON later confirmed that the facility failed to have sufficient nursing staff to provide nursing-related services necessary to attain or maintain residents’ highest practicable well-being, creating an Immediate Jeopardy situation for all 12 residents on the West Hall.

The facility’s own Resident Rights policy stated that residents have the right to reside and receive services in a safe, clean, comfortable, and homelike environment, including treatment and support for daily living. The Facility Assessment Tool indicated that the facility was to identify specific staffing needs, including nights, holidays, and weekends, and to implement a proactive and systematic approach to staffing, including cross-training and use of on-call and agency staff. Despite these policies and tools, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not implement effective contingency measures to cover the West Hall. This failure to follow its own staffing and resident care expectations directly led to the lack of ADL and incontinence care, lack of repositioning, and lack of assistance out of bed for the 12 residents in rooms 209-A through 217-B on the day of the survey.

The surveyors determined that this failure to provide sufficient nursing staff and to ensure that residents received necessary care created an Immediate Jeopardy situation by potentially putting residents at risk of harm or injury. The NHA and DON acknowledged that the facility failed to have sufficient nursing staff to provide nursing-related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 12 affected residents on the West Hall.

Removal Plan

• Facility DON, NHA, Scheduler, and Designee will review current staffing sheets to ensure that adequate staff are present to meet the residents' needs.
• Facility will prepare and review the current emergency staffing policy and procedures to determine appropriate actions in case of emergency staffing needs.
• Facility will review all agency staffing contracts and obtain additional agency staffing contracts as a back-up to current existing agency contracts.
• NHA, DON, Scheduler or Designee will be educated on how to staff the facility to meet the needs of the facility residents.
• Facility NHA, DON, Scheduler or Designee will review the current schedule to ensure adequate staff are scheduled to ensure adequate care is provided and neglect is avoided.
• Facility nursing staff, including agency, will be educated on meeting staffing needs for each nursing unit and sign the education prior to their next working shift.
• The facility will re-align nurse aide assignments to ensure that all residents are taken care of when a shortage is identified.
• The facility will maintain the projected weekend ratios.
• The facility will hold admissions to ensure that adequate staffing is maintained for the current census.
• The facility will maintain the following staffing pattern to meet the needs of the residents: First floor - First shift = 2 nurses/4 nurse aides; First floor - Second shift = 2 nurses/3 nurse aides; First floor - Third shift = 1 nurse/3 nurse aides; Second floor - First shift = 2 nurses/3 nurse aides; Second floor - Second shift = 2 nurses/3 nurse aides; Second floor - Third shift = 1 nurse/2 nurse aides; One RN Supervisor for each shift.
• Facility DON/Designee will perform audits to ensure that the facility staffing meets the care needs for the residents to ensure that no abuse or neglect is identified.
• Results of the audit will be reported to an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee.