F0725

E

Insufficient Vent Unit Staffing Leads to Missed Incontinence Care and Repositioning

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on the ventilator unit to meet residents’ care needs, particularly for incontinent care and repositioning. On the ventilator unit, staffing for a 12‑hour shift consisted of one respiratory therapist, one nurse (LPN), and one CNA for 13 residents (11 ventilator residents and 2 with tracheostomies), most of whom were fully dependent on staff for all care. The facility assessment described the ventilator unit as requiring a higher staff‑to‑resident ratio due to increased needs, yet the actual staffing pattern on the day of survey observation provided only one CNA for the unit. The scheduler confirmed that for 11 residents on the vent unit, she staffs one CNA, and that a second CNA is only added when census reaches 14–15 residents.

During continuous observation from 8:36 a.m. to 1:40 p.m., the surveyor noted that multiple dependent residents did not receive timely incontinence care or repositioning. One resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, a feeding tube, and tracheostomy, who is always incontinent of bowel, was not observed receiving care until approximately 12:31 p.m.; at that time the incontinence product was saturated with urine and the resident had a bowel movement, and the sheet was soiled with stool. Another resident who is comatose, has chronic respiratory failure, encephalopathy, dysphagia, a feeding tube, tracheostomy, and is always incontinent of bowel and bladder, was not observed receiving incontinent care until 12:57 p.m., which was the first care observed for that resident during the five‑hour observation period. A third resident with myotonic muscular dystrophy, chronic respiratory failure with hypoxia, dysphagia, anxiety disorder, a feeding tube, tracheostomy, ventilator, and always incontinent of bowel, was not provided incontinence care and repositioning until 1:18 p.m.; at that time the incontinence product was saturated with dark yellow urine, the sheet under the resident was wet with urine, and there was a large amount of stool on the buttocks and rectal area.

Additional residents with indwelling urinary catheters and bowel incontinence were not observed being checked for bowel incontinence or repositioned during the same five‑hour observation. One such resident, comatose and always incontinent of bowel with an indwelling catheter, had a care plan intervention to be checked every two hours and assisted with toileting as needed, yet the surveyor did not observe the CNA enter the room to provide bowel incontinence care or repositioning. Two other residents with chronic respiratory failure, quadriplegia or anoxic brain damage, feeding tubes, tracheostomies, ventilators, indwelling catheters, and always incontinent of bowel were likewise not observed receiving bowel incontinence care or repositioning during the observation period. The CNA assigned to the unit reported having 12–13 residents, most fully dependent, and stated that rounds are supposed to be every two hours but that she was alone with 13 residents and would “do the best she can.” She also stated that when hired she was told there would be two CNAs per shift on the vent unit, but recently there had only been one.

Interviews with staff and leadership further described the staffing pattern and division of responsibilities that contributed to the deficiency. The respiratory therapist stated they are responsible for airway management and do not routinely reposition residents unless asked to help. The LPN on the unit stated that treatments are done at night, and that she is responsible for medications and tube feedings; she indicated she would assist with repositioning or continence care only if help was needed, and that such care was the CNA’s responsibility. The CNA stated that after initial early‑morning checks to ensure residents were “living and breathing” and to empty catheters, she considered her next check after breakfast as her second round, but acknowledged she did not complete two‑hour checks and changes, stating that residents were “not on a schedule.” The administrator confirmed that the unit was staffed with one RT, one nurse, and one CNA, and acknowledged that what the surveyor observed occurred under that staffing pattern. The scheduler confirmed that one CNA is routinely scheduled for 11 residents on the vent unit and that being down one CNA is not considered an emergency for which bonuses would be offered.

The medical director acknowledged that the facility has challenges with hiring and retention and stated that CNAs can pull help from other areas and that teamwork is key. When informed of the five‑hour continuous observation during which multiple residents’ needs were not addressed, the medical director agreed that staffing one CNA on the vent unit for many dependent residents is an issue. CNAs working on the vent unit reported that staffing is challenging, that there is only one scheduled CNA on the unit at all times, and that most residents are dependent for all care, making it hard to complete all required tasks. They stated that two CNAs are needed on the vent unit to provide necessary care and mobility assistance for the 12–13 residents typically assigned.