Inadequate Staffing Levels Compromise Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaint investigations and observations. The facility's staffing levels were consistently below the required minimums, with reports indicating that the average hours of care per resident per day were significantly lower than the mandated 3.5 hours. Observations and interviews revealed that call lights were left unanswered for extended periods, and residents were not receiving timely assistance with basic needs such as repositioning, toileting, and meal service. Interviews with staff members, including CNAs and LPNs, highlighted the challenges faced due to inadequate staffing. Staff reported being unable to complete their duties, such as providing showers, toileting residents, and assisting with meals, due to the high resident-to-staff ratios. The lack of sufficient staff also led to delays in medication administration and inadequate supervision of residents, particularly those with higher acuity needs or behavioral issues. Residents and their families expressed dissatisfaction with the care provided, citing long wait times for assistance and unmet care needs. The Resident Council and Ombudsman also reported concerns about staffing levels, with residents describing instances where call lights were ignored, and staff were unable to provide timely care. The facility's failure to maintain adequate staffing levels compromised the safety and well-being of its residents, as evidenced by the numerous complaints and observations documented in the report.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The following corrective actions for those residents who were found to have been affected by the deficient practice: Five complaint investigations were conducted (#NY 668, #NY 735, #NY 153, #NY 833, and #NY 434) during annual survey which ended on 1/21/25. It was determined that the facility allegedly did not ensure that there was sufficient staffing on multiple dates throughout the [AGE] year, based on the previously referenced complaints and staff/resident interviews conducted during the annual survey. No residents were affected by this deficient practice. The Social Service Director/designee will review with all residents who are alert and oriented in person and/or will contact the responsible parties of those residents with cognitive impairment, to discuss the facility's active plan to recruit and retain staff. The recruitment and retention plan will be reviewed at the next resident council meeting. The Administrator/designee will also discuss the “Ambassador program” that was created to foster relationships between management team members and new staff. The facility also has a “Manager on Duty” program to assist on weekends with staffing challenges; this includes the majority of management in the facility. Nursing leadership coverage rotates on a weekly basis, with all members of the nursing leadership team assisting with off-hour and weekend assistance. The Daily Nursing report (BIPA) is reviewed daily to ensure the number of nursing hours worked and the number of nursing staff working each shift based on census met the minimum staffing requirements. The facility will work with the Corporate Recruitment manager to discuss alternative recruitment initiatives. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Assistant Director of Nursing ensure the health and wellbeing of the residents by having responsibility for oversight and operations of the nursing department. The DON and ADON, along with the Unit Nursing Managers, have been present on many shifts over the course of the last year. These include occasions when there were call-offs, weather-related issues, and other staffing challenges to help ensure adequate clinical specialists were on-site to provide care to the residents. The facility assessment and minimum staffing plan was reviewed and revised on 2/12/25 to include the use of a supplemental staffing agency. The Emergency Preparedness plan was reviewed on 2/12/25 to address staffing, which includes the use of a supplemental staffing agency. The facility labor disruption policy was reviewed on 2/12/25 to ensure interventions to address insufficient staffing are identified and staff will be re-educated on the process of when to activate the emergency staffing plan. When resident census changes, when staff call off or additional staff are called in to assist with staffing, the number of nursing hours worked, the number of nursing staff working each shift, and census will be updated on the Daily Nursing Report Sheets (BIPA). The Daily Nursing Report sheets along with the Facility Assessment minimum staffing ratios identified in the Facility Assessment will be compared to the daily clinical staffing sheets to ensure clinical daily schedules adequately reflect that staffing minimum hours are being achieved every shift according to the facility assessment. The Administrator, the DON, and the Staffing Coordinator will continue to review staffing daily and implement procedures to ensure sufficient staff are available to meet residents’ needs. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure that this deficient practice does not re-occur, the Administrator/Director of Nursing will provide educational training consisting of but limited to: 1. Facility policy and procedures on Facility Wide Assessment Tool consisting of the facility's clinical minimum staffing requirements. 2. Facility policy and procedures on Labor Disruption Policy and when to activate plan. 3. Facility policy and procedures on Emergency Staffing Plan and when to activate the plan. 4. Facility policy and procedures on completing and reviewing the Daily Nursing Report Sheet. 5. Nursing Managers and Nursing Supervisors will be re-educated on procedures when to notify the Administrator, Director of Nursing, and the Assistant Director of Nursing when there are vacancies and nursing call-offs that impact the facility not meeting minimum clinical staffing requirements as identified on the Facility Assessment. 6. All in-services will be completed by 3/12/2025. Nursing Unit Managers, Nursing Supervisors, and all other nursing exempt staff will be educated by the Administrator/Director of Nursing on the facility's minimum staffing numbers identified in the facility assessment and what to do if the numbers drop below the minimum requirements. This will include what to do, who to call regarding call-offs/no call no shows, and what other nursing personnel to contact to try and fill the vacancy issues when dropping below minimum staffing requirements. A new on-call schedule was developed to provide to backfill vacancies that are unable to be filled. The on-call schedule does not include the DON as the facility census is above 60. Discussions regarding recruitment and retention initiatives will be added to the monthly resident council meeting agenda for three months. Grievances will be reviewed daily for staffing concerns during morning report. The Clinical Staffing Coordinator will audit the daily staffing sheets, the daily nursing report sheets (BIPA), the facility assessment minimum staffing ratios, and the daily census daily for three months to ensure minimum staffing compliance. The Administrator in conjunction with the Director of Nursing will continue to review the facility's schedules weekly for three months to ensure sufficient staff have been scheduled to attain and maintain the highest practicable physical, mental, and psychosocial well-being of residents. With support from the Corporate Recruitment Team and Chief Operating Officer involvement, continued Recruitment meetings will take place weekly to monitor recruitment initiatives. The facility will continue to provide daily staffing needs updates to the Staffing Agency vendor to try and fill daily open shifts. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.