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 required by federal and state regulations. Over a six-day period, the facility did not meet the minimum required 3.5 direct care service hours per patient day (DHPPD), with documented shortfalls on each day. The Director of Nursing (DON) confirmed that the facility was short-staffed, particularly on the night shift, due to the recent resignation of three Certified Nursing Assistants (CNAs) and reliance on temporary staff. Facility records showed that on several days, the DHPPD fell significantly below the required threshold, with the lowest being 2.22 DHPPD. The facility's own policy, which mandates sufficient and competent staffing in accordance with resident care plans and facility assessment, was not followed during this period. This staffing deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for all 95 residents in the facility. The DON acknowledged awareness of the staffing shortfalls and confirmed that the required staffing levels were not maintained on the specified dates. The deficiency was identified during an unannounced complaint investigation related to quality of care, and the findings were corroborated through interviews and review of facility documentation.