Failure to Provide Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment and staffing policy. The facility assessment specified that, for an average daily census of approximately 54 residents, staffing should include six CNA/NA on day shift, four CNA/NA on evening shift, three CNA/NA on night shift, and two CMTs on day and evening shifts. However, review of staffing schedules over several weeks showed repeated instances where only three or four CNA/NA were scheduled on day shifts, and there were also days with insufficient CMT coverage. These staffing levels did not meet the requirements outlined in the facility's own assessment and policy. Interviews and record reviews confirmed that the administrator was responsible for scheduling and was training a new staffing coordinator. The administrator stated that staffing decisions were based on the facility assessment, census, and resident acuity, but also indicated an intention to change the assessment to reflect current staffing practices. The deficiency was identified through observation, interviews, and review of staffing records, which demonstrated that the facility did not consistently provide the number of direct care staff required to meet the needs of all residents as per their own standards.