Failure to Conduct and Implement Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure daily staffing needs were met according to its own facility assessment. Multiple staff members and residents reported frequent CNA shortages, especially during evening and night shifts, resulting in delayed responses to call lights, missed showers, and residents receiving bed baths instead. Staff consistently indicated that management was aware of the staffing shortages but did not consistently provide adequate coverage or assistance. Record reviews of time sheets showed that the number of CNAs working various shifts was consistently below the levels outlined in the facility's own assessment. On several occasions, only one or two CNAs were present for entire shifts when the assessment called for significantly more. Staff interviews confirmed that when CNAs called off or did not show up, their positions were often not filled, and management rarely assisted in covering these gaps. The use of agency staff was only recently implemented, and prior to that, staff were frequently told to do the best they could with the available personnel. Residents reported feeling discouraged from requesting assistance due to staff communicating the ongoing staffing shortages. Staff members expressed concerns that inadequate staffing led to residents not being toileted or changed in a timely manner, increasing the risk for issues such as skin breakdown. The facility's own policy required sufficient and competent nursing staff to meet resident needs as determined by the facility assessment, but documented evidence showed that these standards were not consistently met.