Failure to Maintain Minimum Night Shift Staffing Levels
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the needs of all residents and to comply with minimum staffing requirements for fire safety. According to the facility's own policy, with a census of 54 residents, at least three staff members were required on the night shift. However, review of staff time punches and schedules for two consecutive nights showed that only two staff members, an LPN and a CNA, were present in the building for significant portions of the night shift, specifically from approximately 11:00 P.M. to 4:00 A.M. There was no third staff member present during these hours, and this was confirmed by staff interviews and schedule reviews. Additional staff, such as a CMT or another CNA, were only present for part of the evening and left before the required night shift coverage was met. Interviews with facility staff, including the LPN, CNA, Social Services Designee, and Interim DON, confirmed awareness of the staffing shortfall and that the required number of staff was not maintained during the night shift. The Regional CNO was not aware of the deficiency until it was reported during a call. The deficiency affected all 54 residents in the facility, as the lack of adequate staffing could impact both resident care and fire safety compliance. No specific residents were identified as being directly harmed in the report, but the deficiency was systemic and ongoing over at least two consecutive nights.