Failure to Meet Required Nursing Staff Hours
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the required 3.5 direct care service hours per patient day (DHPPD) as mandated by regulation and the conditions of their staffing waiver. On multiple dates, including May 18, June 6, June 7, June 8, and June 9, 2025, the actual DHPPD fell below the required threshold, with the lowest recorded at 2.50 hours. This shortfall was confirmed through review of staffing assignments and acknowledged by both the Director of Staff Development (DSD) and the Director of Nursing (DON). During the investigation, it was reported by an LVN that a call light was left activated for 40 minutes without a Certified Nursing Assistant (CNA) present to respond, indicating a delay in addressing resident needs due to insufficient staffing. The DSD and DON both acknowledged the facility's failure to meet staffing requirements on the specified dates and recognized the importance of adequate staffing for resident safety and care. The deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for the facility's 95 residents. The facility's staffing waiver required a minimum of 3.5 DHPPD, and the failure to meet this standard was documented and confirmed by facility leadership during interviews and record reviews.
Plan Of Correction
3. We are scheduling registry CNAs to help with staffing requirements and pay for housing for staff. 4. Staffing coordinator & DSD will obtain availability schedule for staff to work during days off. 5. DSD and Administrator reiterated our attendance policy during our all staff meeting on June 5, 2025. D) How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. 1. The staffing coordinator/DSD will report during stand-up meetings the projected PPD for the day and the PPD calculation from the previous day and adjust staffing according to admission and discharge and if there are absences. 2. DSD will report findings during the monthly QA meeting if there are days that fall below the required PPD staffing levels and monitor for trends. 3. We will continue to reward and employee recognition for attendance and morale. We scheduled a shaved ice truck for all staff meetings as well as other local vendors to boost employee satisfaction/attendance. The Director of Nursing will report monitoring results to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months or until substantial compliance is achieved and maintained. The QAPI Committee will make recommendations for additional interventions or modifications as needed. All corrective actions will be completed by 6/29/25.