Inadequate Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to provide adequate staffing to ensure the safety of a resident during bed mobility, which was consistent with the assessed and care-planned needs. The resident, who was non-verbal and dependent on staff for all care, required the assistance of two staff members for bed mobility. However, on the day of the incident, the facility was understaffed due to call-offs, and only one CNA was available to assist the resident. This resulted in the resident falling from the bed and sustaining a head injury, which required a transfer to a higher level of care. The CNA involved in the incident admitted to attempting to care for the resident alone, despite knowing that the resident required two-person assistance. The CNA stated that she tried to lower the bed and call for help when the resident began to fall, but was unable to prevent the fall. The facility's staffing issues were highlighted by multiple staff members, who reported that understaffing was a common problem and that the administration often allowed shifts to continue without adequate replacements. The facility's policies and procedures for care planning and staffing were not effectively implemented, as evidenced by the unresolved care plan issues and the lack of timely reporting and investigation of the incident. The care plan for the resident was not active at the time of the incident, and staff were not aware of the resident's transfer status. Additionally, the facility's administration failed to promptly report the incident to the appropriate authorities, and the investigation was delayed due to the absence of key personnel.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2. A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were by the alleged deficient practice. No other opportunities were identified. Element #3. Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4. The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is , 20225.