Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as determined by its own Facility Assessment. Record review of daily staffing sheets for January and February 2024 revealed that both nursing and certified nurse assistant (CNA) staffing levels were frequently below the minimums established by the facility for various shifts on the 2nd floor. Specific deficiencies included shifts with only one nurse or fewer CNAs than required, and several instances where no nurse or only one CNA was scheduled for a shift, contrary to the documented staffing requirements. The facility's policy stated that sufficient numbers of nursing staff would be provided in accordance with care plans and the facility assessment, but actual staffing did not consistently meet these standards. Interviews with facility leadership confirmed awareness of staffing shortages, particularly on weekends, and acknowledged that agency staff were sometimes used to fill gaps. The Director of Human Resources and nursing leadership described processes for attempting to cover shifts, such as using a staff roster and supervisors or assistant directors of nursing stepping in when needed. However, there were documented occasions when no nurse was scheduled for a unit, and leadership could not recall or confirm all such instances. These findings demonstrate that the facility did not consistently ensure adequate nursing coverage as required by regulation and its own assessment.