Insufficient Nursing Staff Leading to Delayed Care, Poor Hygiene, and Unmet Toileting Needs
Penalty
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff with appropriate competencies and in adequate numbers on a 24-hour basis to meet residents’ assessed needs and care plans, as required by its facility assessment and federal regulations. The facility assessment dated 4/14/25 stated that staffing would follow state-required ratios to meet per patient day needs for ADLs, mobility and fall prevention, bowel and bladder care, and prompt response to bathroom assistance to maintain continence and dignity. However, multiple resident interviews, observations, Resident Council minutes, confidential group interviews, and grievance reviews showed that residents frequently experienced delayed or missed care, including long call light response times, inadequate toileting assistance, and insufficient hygiene and ADL support. Several residents reported prolonged waits for assistance and unmet toileting needs. One resident who stated she was not incontinent reported that staff did not help her onto the bedpan despite repeated requests, causing painful bladder holding and long call light waits, and she also reported not always receiving fresh water. Another resident reported having to leave her room to find staff to assist her roommate. Multiple residents described call light response times as very long, sometimes four to five hours, and one resident confirmed being left in a soiled brief for a long time, resulting in skin irritation. Observations included a resident with greasy-appearing skin and an unclean face who reported rushed care and late meals. Resident Council minutes over several months documented ongoing concerns about call light response, staff not being present on the floor, residents not being gotten out of bed, residents left in the dining room after meals, and call lights being shut off without care being provided. During a confidential resident group interview, numerous residents reported that staff turned off call lights without providing care, that residents needing assistance in and out of bed were not reliably helped, and that they experienced extremely long waits to be put to bed or assisted off bedpans. Specific accounts included being left in a chair from late morning until late at night with swollen, painful legs; being left on a bedpan through dinner after staff failed to return; sitting in urine and feces for up to eight hours with only cream applied over unwashed skin; and having to call family to contact staff because call lights were not answered. Grievances further documented concerns about lack of oral care, poor hygiene, unchanged bed linens, soiled pads with urine and feces, residents not being set up for meals in bed, being told to use briefs instead of a urinal, missed showers, and not being assisted to bed until midnight. The Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable well-being of multiple residents over several months.
Plan Of Correction
The facility will provide for sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being. Staffing levels will be developed to meet the needs of the resident's care examples are ADL care, Incontinent care Transferring ,meal time, nail care, linen changes based on the facility assessment results. The facility will do this by Working with Veeshift/Eshift Staffing agency and Dropstat a scheduling oversite company to look at staff schedule to optimization the staff required to provide resident Care. The HR Director will develop a hiring plan based on the needs presented by the company Dropstat.Monthly staff meetings will be held by the HR Director to understand the needs of the staff and promote staff retention.Education will be provided To the nursing staff regarding What to do when unable to complete a care task. That they need to follow the change of command and let the nurse know they can not complete the task the nurse will then complete the task or notify their supervisor. Documentation will be completed by the staff or manager that completes the task. The Administrator/Designee will audit daily nursing staff to ensure the required number of staff are present to provide for sufficient nursing staff to meet the residents' needs. the DON/Designee will audit 90% of residents who have care concerns weekly times four and monthly time two Results of these audits will be presented to the QAPI committee for review and recommendations
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