Failure to Maintain Sufficient Nursing Staff
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, as evidenced by multiple instances of low staffing, particularly on weekends. Facility-submitted data to CMS for the first quarter of the year showed excessively low nursing staffing on weekends. Staffing and sign-in sheets revealed repeated call-offs across several weekends, with the facility attempting but not always succeeding in filling these gaps. Interviews with CNAs, an RN, an LPN, and the facility scheduler confirmed ongoing staffing challenges, especially with CNAs, and frequent reliance on agency staff. Staff reported that when short-staffed, they had to modify care routines, such as providing bed baths instead of showers, and nurses had to assist with CNA duties. The scheduler and administrator acknowledged persistent issues with staff call-offs and open positions, and recent efforts to use agency staff to address shortages. A confidential group interview with residents revealed that some experienced delayed responses to call lights and missed showers, particularly on weekends and overnight shifts, due to insufficient staffing. Three out of ten residents specifically voiced concerns about long wait times and missed care. The facility assessment indicated that staffing was supposed to be based on resident population and acuity, but the reported events and interviews demonstrated that staffing levels were not consistently adequate to meet resident needs.