Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, as identified during a Recertification Survey conducted from December 15 to December 23, 2024. The deficiency was noted across all seven units reviewed, with specific issues related to low weekend staffing levels. The Payroll-Based Journal (PBJ) Staffing Data Report for Quarter Three of 2024 indicated excessively low weekend staffing, resulting in a One Star Staffing Rating. The facility's staffing plan, as outlined in the Facility Assessment, was not adhered to, with several instances of insufficient Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) on duty during weekends. The Facility Assessment, updated in June 2024, documented the required staffing levels for each unit, which were not met on numerous occasions. For example, Unit 1 East was found to have only one LPN on several weekends, despite the requirement for three LPNs during the 7:00 AM to 3:00 PM shift. Similar staffing shortages were observed in other units, with some units having only three CNAs instead of the required five. These staffing deficiencies were consistent and repeated, indicating a systemic issue within the facility's staffing practices. Interviews conducted during the survey revealed that the facility's staffing coordinator acknowledged the ongoing staffing shortages, particularly on weekends, and noted that the use of an agency had not resolved the issue. The Director of Nursing Services was unaware of the facility's low weekend staffing rating in the PBJ and admitted to challenges in hiring and retaining staff. The facility administrator also acknowledged the difficulty in attracting and retaining nursing staff, which contributed to the failure to meet the staffing levels outlined in the Facility Assessment.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 F 725 – Sufficient Staffing The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: Immediate corrective action of the discrepancy between staffing levels and the facility assessment could not be completed as the staffing levels for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 cannot be altered. All Incident reports and grievance logs were reviewed for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 to ascertain if there were any reports or grievances as a result of the alleged deficient practice. There were no residents identified as harmed or affected as a result of this deficient practice. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. An audit tool will be created and a retrospective review (10% audit) will be completed reviewing the staffing levels of licensed nurses and certified nursing assistants for the months of (MONTH) 2024 through (MONTH) 2024 to determine any shifts of excessively low staffing in conjunction with the facility assessment. After identification, all incident reports and grievance logs for the same time period will be reviewed to ascertain if there were any reports or grievances as a result of the alleged deficient practice. The Facility Assessment will be reviewed and adjusted to reflect the actual staffing of the units for licensed nurses and certified nursing assistants. The Director of Nursing in conjunction with the Staff Scheduler will review staff levels weekly prior to the following work week to ensure adequate staffing levels on each unit based on acuity and facility needs. Person responsible: Director of Nursing C) Systemic Changes to ensure the deficient practice will not recur: The facility has implemented the following process in an effort to recruit staff especially Certified Nursing Assistants: - Agency contracts are in place - Staff members are offered overtime - Qualified walk-ins are hired immediately after the interview process with an emphasis towards weekend staffing levels - A full-time recruiter is on staff to assist the facility with staffing needs - The facility is offering sign-on bonus and referral bonus - The facility hosts job fairs and open houses - Staff are offered flexible schedules - The facility has a presence on social media and online advertising Person responsible: Administrator/Designee D) QA – Monitor of the deficient practice: A 10% audit will be completed monthly x 6 months reviewing the staffing sheets to determine any shifts of excessively low staffing, specifically Certified Nursing Assistants. Any negative findings will be presented to QAPI to determine further discuss specific reasons and corrective measures relative to nursing staffing needs, especially with Certified Nursing Assistants. The Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025