Staffing Shortages in Facility
Penalty
Summary
The facility was found to have insufficient staffing levels during a recertification survey conducted from March 5 to March 12, 2025. The survey revealed that on multiple occasions, the number of Certified Nurse Aides (CNAs) on duty fell below the minimum required levels across various shifts and units. Specifically, the staffing shortages were noted on several dates in February and March 2025, affecting all three units (A, B, and C) during different shifts. The minimum staffing requirements were not met, with instances of only one CNA present when two or more were required, particularly during the night shifts. During an interview, the Director of Human Resources and Staffing acknowledged the staffing shortages and attributed them to high turnover rates and challenges in filling weekend shifts. The Director mentioned that they sometimes had to reassign CNAs from units with lower census to cover shortages and offered overtime and incentives to encourage staffing. Despite these efforts, the facility experienced staffing shortages on the specified dates, although the Director could not confirm if these shortages directly impacted resident care.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) Tag-F725 I. Immediate Corrective Action: The Administrator, DON and HR Coordinator furthered Facility recruitment efforts including: 1) contacted CNA Training program(s) LIST 2) contacted 1199 SEIU Hiring division 3) contacted additional Staffing agencies. 4) The facility posted ads for recruitment for all open positions in the facility with Apploy and Indeed. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The Social Service Department conducted an audit with randomly selected alert residents on each unit to identify any issues related to staffing concerns and resident care issues. There were no identified issues. III. Systemic Changes: 1) The DNS and Administrator reviewed and revised the Facility Assessment to document sufficient staffing needs for each unit based on: Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. 2) An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. The number of Nursing staff to provide services to residents and assist and monitor aides. 3) The DNS provided all Nurse manager staff with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: The responsibility of the RNS to check staff at the beginning of each shift. The need to have a contact list of available staff and agencies to be called in as needed. The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes. The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. The responsibility of the RNS to ensure resident medications, treatments and care are provided in accordance with resident plan of care. The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. IV. Quality Assurance: 1) The Administrator, in conjunction with the DNS developed an audit tool to ensure that staffing levels are monitored, and all residents receive required services in accordance with resident plan of care. This audit will be done for each unit weekly x 4 weeks and monthly for 11 months. 2) The HR designee will audit the Staffing to identify date, shift and unit that had less than sufficient staffing weekly x 4 weeks followed by monthly x 11 months. 3) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Person Responsible: DON