Staffing Shortages on Weekends Lead to Deficiency
Penalty
Summary
The facility was cited for not ensuring sufficient nursing staff were available to provide necessary services to assure resident safety and wellbeing. The deficiency was identified during a recertification survey conducted from March 2, 2025, to March 7, 2025. The facility's staffing policy, last reviewed in September 2024, mandates adequate and competent staffing levels based on the facility assessment. However, the Payroll Based Journal Staffing Data Report for the fourth quarter of 2024 indicated excessively low weekend staffing, which was confirmed by reviewing the actual weekend staffing schedules. The facility assessment tool, updated in January 2025, outlined a staffing plan for a capacity of 102 residents, but discrepancies were noted in the actual staffing levels on weekends. The report detailed specific instances of staffing shortages on weekends from July to September 2024. These shortages included missing Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) on various shifts across the East and West Wings. Interviews with residents revealed that they experienced delays in receiving assistance, particularly at night, due to insufficient staffing. One resident mentioned that it took too long for staff to respond when they requested help, while another resident noted a lack of staff, especially during nighttime hours. Interviews with facility staff, including CNAs and the Staffing Coordinator, confirmed the occurrence of staffing shortages on weekends, often due to call-outs. The Director of Nursing (DON) stated they were unaware of the low weekend staffing or the Payroll Based Journal trigger for low staffing during the specified quarter. The Administrator acknowledged awareness of the Payroll Based Journal trigger but was unsure of the reasons, attributing it to changes in CMS measures rather than actual staffing level changes. The Administrator also mentioned that staffing levels had not changed significantly and had improved compared to previous years, despite the facility triggering worse under the updated measures.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 Residents #67 and #32 were interviewed about their concerns of short staffing on the weekends to efficiently address their concerns. Residents were updated on the plan of correction to ensure that the facility is fully staffed. Element #2 On weekends, the facility will schedule an extra CNA to each shift as padding to cover for call outs. The Staffing Coordinator and the Shift RN Supervisor will be educated that overtime may be used to cover call outs. Element #3 The facility will post ads to attract and hire more staff. The facility will update the policy that all weekend shifts will have padding of an extra CNA on all weekend shifts and overtime may be used to cover available shifts. All RN supervisors and the staffing coordinator will be in-serviced by the Director of Nursing on the new policy. Element #4 An audit tool will be developed by the Director of Nursing and completed weekly for three months to ensure the facility has sufficient weekend staffing. The Director of Nursing will submit a status report to the administrator on a weekly basis for three months. The Director of Nursing will present the findings and corrective actions if indicated to the QAPI committee, and thereafter the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25