Deficiency Due to Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. The census was reported at 69, with a significant portion of residents dependent on staff for care, including a ventilator unit. Several complaints were received by the State Agency alleging insufficient staffing, which resulted in unmet care needs such as failure to prevent worsening of pressure ulcers and avoidable falls with injury. The CMS PBJ Staffing Report also indicated excessively low weekend staffing. Specific resident cases highlighted the impact of insufficient staffing. One resident, with a history of hip fracture and high fall risk, suffered a fall resulting in rib fractures. Staff reported that necessary safety equipment, such as positioning wedges, was not in place at the time of the fall, and the resident's wife had to remain at the bedside due to concerns for safety and confusion. Another resident, dependent on staff for all care, experienced worsening and new pressure ulcers, with documentation showing missed wound treatments and incomplete turning and repositioning logs. Additional residents experienced missed showers, oral care, and repositioning, with documentation reflecting numerous shifts where required care was not provided or not documented as completed. Interviews with staff, residents, and family members consistently reported ongoing staffing shortages, particularly on second and third shifts, leading to basic care needs not being met. Staff described being unable to provide care as frequently as required, with restorative staff being pulled to cover floor duties and managers picking up shifts to meet minimum requirements. Resident council and grievance forms further corroborated concerns about missed care and insufficient staffing, with reports of residents being left in soiled conditions and not receiving scheduled showers or repositioning.
Plan Of Correction
Element 1: The facility assessment has been updated by 4/25/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to delay in call light response time by the Director of Nursing/Designee by 4/25/25 and did not have any negative outcomes. Residents’ concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 4/25/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 4/25/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 4/25/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including staffing to meet resident needs. This education will be completed by 4/25/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.