Insufficient Licensed Nursing Staff Leads to Immediate Jeopardy
Penalty
Summary
Facility staff failed to provide sufficient licensed nursing staff to meet the needs of all residents, as required. The Director of Nursing (DON) and Unit Managers (UMs) were frequently required to work as floor nurses or CNAs due to staffing shortages, which limited their ability to monitor and maintain essential facility processes, including laboratory services. The facility's own assessment indicated an average daily census of 98 residents, and CMS Payroll Based Journal data showed a one-star staffing rating for the previous four quarters. During the survey, it was found that the facility averaged only two to three licensed nurses on night shift, below their stated goal of four per shift, and relied on agency staff and management to fill gaps. As a result of these staffing issues, surveyors identified concerns for four residents related to failures in timely laboratory test completion, communication of abnormal results to medical providers, ensuring provider response, and timely implementation of orders for abnormal results. These failures led to the identification of an immediate jeopardy situation. Both the DON and the Administrator acknowledged that the need for management to cover floor shifts contributed to the breakdown in facility processes, particularly regarding laboratory services.