Insufficient Night Shift Staffing Resulted in Delayed Incontinent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff during one of two reviewed night shifts, specifically the 11 pm to 7 am shift, resulting in inadequate incontinent care for a resident. On the night in question, only two CNAs were on duty for a census of 89 residents, whereas the facility's policy and facility assessment indicated that four to six CNAs were typically required for this census, with an expected ratio of 12 to 16 residents per CNA. As a result, the two CNAs were assigned to care for 33 and 40 residents each, which was significantly above the usual assignment and made it difficult for them to provide timely care to all residents. A resident with a history of Type 2 diabetes mellitus with a foot ulcer, mobility issues, and frequent incontinence was not checked or changed throughout the night, contrary to their care plan, which required checks for bladder incontinence at least every two hours. The resident reported that staff did not check or change them during the night and attributed this to the reduced number of staff on duty. Staff interviews confirmed that the night shift was short-staffed, and licensed staff had to assist with ADL care, which was not typical and caused delays in their other duties. Facility records and staff interviews indicated that management was aware of the staffing shortage and attempted to find replacements but was unsuccessful. The facility's own policy and facility assessment required sufficient numbers of nursing staff to meet residents' needs, but this was not met on the night in question, leading to a delay in the provision of care and services for the affected resident and potentially others.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3's needs were immediately addressed to ensure their care needs were adequately met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/28/25, department supervisors conducted rounds to ensure that no other individuals were impacted by this deficiency. No additional issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: A in-service training was conducted on 4/1/2025 with the DSD and DON by the Administrator, focusing on the importance of sufficient staffing and meeting staffing per patient day (PPD) requirements. On 10/29/24, QAPI centered on sufficient staffing created by Administrator/DON. The QAPI is ongoing. The facility will reinforce and ensure adherence to the 4-2 staffing ladder for CNAs. The Director of Staff Development (DSD) will be responsible for ensuring adequate CNA coverage for the AM, PM, and NOC shifts. The DSD will report any staffing shortages to the administrator daily (Monday-Friday) during morning stand-up meetings to ensure effective communication regarding CNA and licensed nurse staffing levels. The Administrator/designee will collaborate with the organization's HR Recruiter to ensure CNA hiring efforts remain a hyper-focus. The facility is working closely with a dedicated recruiter to prioritize the recruitment of qualified nursing staff. This partnership focuses on sourcing, screening, and hiring skilled nursing staff. The facility will also collaborate with sister facilities in an effort to meet staffing needs as needed. The facility will continue to implement a bonus incentive on an as-needed basis for licensed nurses/CNAs, effective January 27, 2025, to help maintain adequate staffing levels and effectively address staffing needs. The DSD/designee will continue to maintain a call log when staffing hours for CNAs are insufficient. The log will document all staff members contacted and the outcomes of those communications. The DSD/designee will report any pattern of findings related to staffing to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QM committee determines compliance. Date of Compliance: April 1st, 2025