Staffing Shortages Lead to Deficiency in Resident Care Hours
Penalty
Summary
The facility was found to have insufficient nursing staff to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Between March 23, 2025, and March 31, 2025, the facility failed to meet the minimum hours of nursing care per resident day as established by the Centers for Medicare and Medicaid Services (CMS). The facility's average daily census was 110, and the documented nursing levels equaled 3.07 hours per patient day, which was below the required 3.5 hours per day per resident. The staffing levels were consistently below the required minimum, with significant shortages in Certified Nurse Aides (CNAs) and Licensed Nurses on multiple days. The facility's staffing plan indicated efforts to maintain adequate staffing levels, but the actual staffing sheets from March 23 to March 31, 2025, showed that the facility was short of the required staffing hours on eight out of nine days. For instance, on March 23, 2025, with a census of 115 residents, the facility was short by 66.5 hours of staffing care, and on March 29, 2025, with a census of 115, the facility was short by 82.5 hours. The facility attempted to mitigate these shortages by having Licensed Practical Nurses (LPNs) work as CNAs and adopting a team approach to resident care. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility struggled to hire CNAs, attributing the difficulty to its remote location. The facility employed various strategies to recruit and retain staff, including working with recruiters, offering incentives, and providing flexible schedules. Despite these efforts, the facility continued to experience staffing shortages, impacting its ability to meet the CMS guidelines for resident care hours.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 There was no identified negative effect specified for any individual resident resulting from this deficient practice. The facility assessment has been updated to read: "The facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis." The in-house census along with resident acuity and care needs were reviewed by the Director of Nursing and compared to the staffing levels currently being scheduled. The scheduled staffing levels for the week ending (MONTH) 19, 2025 were determined to be in accordance with the staffing levels outlined in the facility assessment. All residents have the potential to be affected by this deficient practice. All resident and/or family concerns regarding staffing are addressed directly by the Administrator or Director of Nursing. The nurse unit managers and/or shift supervisors conduct unit rounds at a minimum of 3x/shift observing each patient to ensure that resident needs are met and care is being delivered according to their care plans. On a daily basis, the Director of Nursing or designee will monitor compliance with medication administration records, treatment administration records, 24-hour report and Certified Nursing Assistant's care documentation to verify that all care was delivered as scheduled. In addition, all quality measures are monitored on a weekly basis and used to identify any care deficit that may relate to inadequate staffing. Any identified care deficit is addressed with re-education of the caregiver and/or formal disciplinary action. The facility assessment was reviewed and updated to read: "The facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis." Unit Managers/Registered Nurse Supervisors were educated on the need to report insufficient staffing on their units to the Director of Nursing or Staffing Coordinator. The Staffing Coordinator was educated to report insufficient staffing to the Director of Nursing/Designee and Administrator. Additional recruitment efforts such as holding an open house for hiring, increased online job postings, in-house referral incentives were initiated to ensure sufficient staffing for all shifts. Orientation for new hires is scheduled every week (or more as needed) to increase the staffing level. A contingency staffing plan was developed to ensure coverage for any call outs and emergency staffing shortages; including incentive bonuses for staff to work additional shifts, and the use of additional nursing staffing agencies. The facility developed a weekly staffing audit tool to ensure that each shift meets the minimal required staffing levels, tracking the number of actual hours per day of nursing staff compared to the staffing levels outlined in the facility assessment. The Director of Nursing/Designee and Staffing Coordinator will review the audit weekly to ensure compliance with staffing levels. The Director of Nursing/Designee will conduct weekly staffing audits for compliance weekly for four weeks. The results of these audits will be reported to the Quality Assurance Performance Improvement committee monthly, who will determine the need for monitoring and reporting until compliance is achieved. Any trends or patterns of non-compliance will be identified, and additional training or corrective measures will be implemented as necessary. The Director of Nursing or Designee is responsible for this plan of correction.