Insufficient Nursing Staff Leading to Poor Hygiene and Delayed Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs for activities of daily living (ADLs), hygiene, and timely response to call lights. Facility policies required timely responses to residents’ requests and provision of services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Observations on the same day showed multiple residents with poor hygiene: one resident had a large amount of brown substance under very long, curled fingernails; another had a large amount of dandruff and dry skin crusted on his hair; a third resident also had a large amount of brown substance under his fingernails; and a fourth resident had a large amount of brown substance under his fingernails and nodded affirmatively when asked if he wanted his facial hair shaved. Review of point-of-care documentation for these residents over approximately one month showed missed or inconsistently provided showers and bed baths, including multiple entries marked as “Not Applicable,” “No documentation,” or only occasional bed/towel baths, despite the residents being present in the facility on those dates. Multiple residents reported concerns about staffing and care responsiveness. One resident stated that call light response times could be excessive and depended on which staff were working. Other residents stated that the facility was short-staffed, very understaffed, and that this stressed the aides and was not good for the patients. Additional residents reported that staffing was sometimes adequate, that they could always use more help, and that there were delays in getting people dressed and out of bed in the morning, with call lights taking a long time because there was not enough staff. Staff interviews corroborated these concerns, with four employees describing staffing as poor, variable, and resulting in them working short on day shift and having to pick up on evenings and days off. The Nursing Home Administrator and DON confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for ten of fifteen residents reviewed.
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