Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where the Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) hours fell below the required minimums. Record review showed that on several dates, the actual DHPPD and CNA hours did not meet the 3.5 and 2.4 minimums, respectively, as mandated by state guidelines. The Director of Nursing (DON) validated these findings during a concurrent interview and record review. The Director of Staff Development (DSD) confirmed that the facility has implemented CNA classes and occasionally receives staffing support from a sister facility or administrative staff who are licensed CNAs, but last-minute call-ins due to family emergencies have contributed to staffing shortages. A review of facility fall logs during the period of insufficient staffing revealed multiple resident falls and two hospital transfers. Specifically, one resident fell on one date, two residents fell on another, and two residents fell on a subsequent date, with two hospital transfers occurring during the same timeframe. There were no reported missed or medication errors within the period reviewed. The facility's policy on adequate staffing states that sufficient staff must be maintained on each shift to meet resident needs, but the documented staffing levels did not consistently meet this standard.