issue-brief Pharmacy Skilled Nursing Facility snf SNF Staffing

Nurse Staffing Deficiencies || Center for Medicare Advocacy

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Most nursing amenities shouldn’t have enough numbers of nurses to offer the care that residents want.  The result’s poor care outcomes for residents – avoidable strain ulcers, medicine errors, inappropriate use of psychotropic drugs, failure to help residents with actions of every day dwelling, avoidable weight reduction, falls, and extra.   The issue of inadequate staffing, and inadequate enforcement of staffing deficiencies, is long-standing.

In 2014, the Middle for Medicare Advocacy checked out nurse staffing deficiencies that the Facilities for Medicare & Medicaid Providers (CMS) cited within the four-year interval 2010-2013.  In an Alert entitled “Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned,” the Middle reported that CMS cited few staffing deficiencies and that monetary penalties for even probably the most critical deficiencies – these labeled “immediate jeopardy” – have been rare.[1]

In December 2018, the Middle once more reviewed deficiencies cited by CMS for inadequate nurse staffing, this time, between November 28, 2017 (the efficient date of the brand new, uniform federal survey course of) and December 18, 2018.[2]  Whereas CMS cited many extra staffing deficiencies than it did within the Middle’s earlier evaluation, it continued to categorise most of them as “no-harm” and to impose few enforcement actions for these it labeled “actual harm” or “immediate jeopardy.”

On this interval of little multiple yr, CMS cited 781 staffing deficiencies, F725 (inadequate employees), representing .5% of the roughly 14,00zero nursing amenities nationwide.  CMS cited the overwhelming majority of deficiencies (96.eight%) as “no harm:”

Staffing Deficiencies, Nov. 28, 2017-Dec. 18, 2018

Complete: 781 Deficiencies

Degree of staffing deficiency

Variety of amenities cited with deficiency at this degree

Proportion of complete staffing deficiencies cited at this degree

Instant jeopardy



Precise hurt



No hurt



Substantial compliance



As mentioned under, and as of December 18, 2018, CMS had not imposed any enforcement motion towards 11 of the 23 amenities whose staffing deficiencies it labeled as precise hurt or fast jeopardy.

Speedy Jeopardy Deficiencies in Nurse Staffing

The Middle appeared on the 17 nursing amenities that CMS cited with fast jeopardy deficiencies in adequate staffing to find out whether or not the deficiencies have been cited following annual surveys or grievance investigations; the amenities’ star scores in staffing; and whether or not CMS imposed any enforcement actions, as of December 18, 2018, as reported on Nursing Residence Examine.

Sort of Survey

In accordance with Nursing House Examine, CMS cited 12 amenities with fast jeopardy in staffing following annual survey and 5, following a grievance survey.

Star scores in staffing for the 17 nursing amenities with speedy jeopardy deficiencies in nurse staffing:

  • 5 amenities had one star in staffing, with an icon indicating that the power didn’t report nurse staffing knowledge, didn’t report auditable staffing knowledge, or had no less than seven days within the quarter with no registered nurse on-site.
  • One facility had two stars in staffing.
  • 5 amenities had three stars in staffing.
  • 5 amenities had 4 stars in staffing.
  • One facility had 5 stars in staffing.

Enforcement for instant jeopardy deficiencies in nurse staffing

Nursing Residence Examine identifies federal enforcement actions (civil cash penalties, CMPs, or denials of cost for new admissions, DPNAs) for solely seven of the 17 amenities whose surveys included an instantaneous jeopardy nurse staffing deficiency.  (It’s attainable that CMS imposed CMPs towards further amenities.  Nevertheless, if a facility appeals a CMP, CMS doesn’t publicly publish the CMP whereas the attraction is pending.)

  • One facility had DPNA as the one treatment imposed.
  • Three amenities had CMPs solely ($11,580; $13,826; $407,673).
  • Three amenities had DPNAs in addition to CMPs ($139,807; $64,558; $16,559)
  • Ten amenities had neither DPNA nor CMPs imposed.

Precise Hurt Deficiencies in Staffing

The Middle appeared on the six nursing amenities that have been cited with an precise hurt deficiency in staffing to find out whether or not the deficiencies have been cited following grievance investigations or annual surveys; the amenities’ star scores in staffing; and whether or not CMS imposed any enforcement actions, as of December 18, 2018.

Sort of Survey

CMS cited 5 amenities with precise hurt in staffing following annual survey and one, following a grievance survey.

Star scores in staffing for the six nursing amenities with precise hurt deficiencies in nurse staffing

  • No facility had one or two stars in staffing
  • Two amenities had three stars in staffing
  • Two amenities had 4 stars in staffing
  • Two amenities had 5 stars in staffing

Enforcement for precise hurt deficiencies in nurse staffing

Nursing House Examine identifies enforcement actions for solely 4 of six amenities whose surveys included precise hurt nurse staffing deficiencies (though, as famous above, any CMPs appealed by amenities wouldn’t be posted through the pendency of the attraction):

  • Two amenities had DPNAs as the one treatment listed.
  • Two amenities had CMPs solely ($13,627, $43,544) (averaging $28,586).

How Staffing Deficiencies are Described within the Survey Stories (CMS-2567)

Instant Jeopardy Staffing Deficiencies

The Middle reviewed three survey studies for amenities that have been cited with speedy jeopardy deficiencies in staffing. 

Good Shepherd Well being Care Middle of Santa Monica

The January 16, 2018 survey by the California state survey company, an annual survey, cited 21 deficiencies.  Along with the jeopardy-level deficiency in staffing, the power acquired two different jeopardy deficiencies – neglect and Medical Director.  4 harm-level deficiencies mirrored issues in help with actions of day by day dwelling (ADL), strain ulcer care, vary of movement, and enough meals/fluids to take care of well being. 

The adequate staffing deficiency within the prolonged CMS-2567 type consists of cross-references to different outcomes deficiencies, particularly neglect (F600), ADLs (F677), strain ulcer care (F686), and offering meals and fluids to take care of well being (F692), the 4 outcomes deficiencies that have been all cited as precise hurt.

The adequate staffing deficiency describes intimately the failures for numerous residents consists of within the pattern.

  • Resident 29 didn’t get correct remedy for tooth ache and a attainable urinary tract an infection; she didn’t get a wheelchair or eyeglasses.  Lack of entry to her wheelchair made her depressed and withdrawn and stored her from actions within the facility.
  • Resident 34 didn’t get help with consuming and consuming and suffered weight reduction and dehydration, resulting in hospitalization.
  • Resident 28 didn’t obtain vital incontinence care and repositioning, leading to a stage II strain ulcer.
  • Resident 12 didn’t obtain help with meals and misplaced 10.5% of his weight in six months.

Further proof:

  • A licensed nurse assistant/restorative nursing assistant (RNA) reported that the power is short-staffed, stopping RNAs from offering RNA providers.
  • Resident council minutes expressed considerations about inadequate staffing.
  • Resident 29 advised surveyors that there have been not sufficient employees to assist her get right into a wheelchair; that she shouldn’t be given a bowl for a number of days to scrub her face; that she doesn’t all the time obtain a water pitcher.
  • Resident 12 referred to as for assist and employees didn’t reply.
  • Member of the family advised surveyors that employees tried to offer her father another person’s dentures; employees don’t change father; father has worn the identical shirt for three days; father not given Guarantee between meals.
  • Ombudsman acquired nameless report about staffing scarcity, indicating that residents had not been bathed and households and residents feared retaliation.
  • The administrator informed surveyors that the staffing was adequate as a result of the residents have been solely “custodial” and didn’t want drugs on the night time shift; the administrator was unable to elucidate how one LVN and one CNA have been adequate to deal with 38 residents on the night time shift, when she had earlier advised surveyors that there must be three CNAs.
  • Resident 9 advised surveyors that typically company employees are available however that they don’t obtain an orientation and will not be conscious of residents’ wants.

As of December 18, 2018, CMS had not imposed a CMP or DPNA towards the power.  The power had a one-star score in staffing, with an icon.

Rolling Hills Rehab and Care Middle

The December 22, 2017 survey by the Ohio state survey company was an annual survey that cited 47 deficiencies, together with 5 jeopardy-level deficiencies and 6 harm-level deficiencies.  The 4 non-staffing jeopardy deficiencies concerned abuse, insurance policies to stop abuse, reporting abuse, and responding appropriately to allegations of abuse.

The enough staffing deficiency consists of the next documentation:

  • A nurse aide with a pending abuse/neglect allegation continued to work within the facility and supply care to residents, together with the resident who made the allegation of abuse, because of lack of obtainable employees.
  • No employees responded to the surveyors once they arrived at 5:25 a.m.  A resident responded to the door alarm and reset the alarm.
  • Surveyors noticed employees getting into residents’ rooms with name lights and turning off the lights, however not offering any care.
  • 20 of 52 residents recognized as alert and oriented stated they believed the power didn’t have sufficient employees.

As of December 18, 2018, CMS had not imposed a CMP or DPNA towards the power.  The power had a four-star score in staffing.

LaPorte Well being Care Middle

The April 10, 2018 grievance survey by the Texas state survey company cited eight deficiencies, together with 4 fast jeopardy deficiencies (degree L).  The three non-staffing jeopardy deficiencies concerned neglect, supervision, and administration.

Surveyor documentation of the staffing deficiency included the next findings:

  • The power didn’t have a licensed nurse always and enough aides to offer care to residents.  When the surveyors arrived at 5:20 A.M. and rang the doorbell, nobody answered the door.  When a licensed vocational nurse and aide arrived at 5:25 A.M., there was solely a single aide within the constructing.
  • Because of a fireplace greater than a month earlier, the power was on hearth watch.  The administrator rotated numerous division heads to be on hearth watch, however nursing employees additionally have been accountable for hearth watch along with their different duties.
  • Resident three, who wanted help for transfers, toileting, and bathing, didn’t have a guide name bell close to her mattress.  She stated the power wanted extra employees.  She gave her name bell to a different resident, who didn’t have one, and used her telephone to name for assist.
  • Resident 7 didn’t have a guide name mattress in his room.  He required complete help for mattress mobility, transfers, showers, dressing, and hygiene.  He stated there have been no employees on his aspect of the constructing.
  • Resident Four, who required complete help for mattress mobility, transfers, toileting, and bathing, was ready to get away from bed at 9:55 A.M.
  • Resident 7 didn’t have a guide name bell in his room.  He was ready for somebody to help him into his wheelchair.
  • Resident 5 stated the power didn’t have sufficient employees and that he needed to wait greater than an hour for drugs.
  • Resident eight informed surveyors that residents needed to wait for hours for help.
  • Surveyors’ evaluation of Worker Time Playing cards discovered a number of days when a single aide was onsite to offer care to the power’s 30 residents.  On some shifts, there was one LVN and one aide for 30 or 34 residents.

As of December 18, 2018, CMS imposed a CMP of $139,807 and DPNA towards the power.  The power had a one-star score in staffing, with an icon.

Hurt-level Deficiencies

Regency Care of Morris

The January 10, 2018 annual survey on the Illinois nursing facility cited 16 deficiencies, together with 4 on the precise hurt degree (pores and skin integrity, supervision, incontinence care, and staffing).  The CMS-2567 describes the harm-level staffing deficiency, degree G, as based mostly on the care of 5 of 16 sampled residents:

  • The power assessed Resident 57 as in danger for pores and skin breakdown.  A nurse aide offered Resident 57 with incontinence care at 11:23 A.M.; he had not been checked or modified since 5:55 A.M., though the power requires residents to be checked each two hours.  The aide stated she didn’t have sufficient time to verify on Resident 57 earlier.  Resident 57 had pores and skin breakdown and developed facility-acquired Moisture Related Pores and skin Deterioration. 
  • Resident 22 was not modified between eight:00 A.M. and 11:11 A.M.  The aide described being brief staffed.
  • Resident 61 was showered at 12:22 P.M. as incontinence care; he had not been offered incontinence care since 6:00 A.M.
  • A nurse advised surveyors that she can be late giving a medicine to Resident 11 until she might discover one other employees member to go to the eating room.  The power thought-about staffing the eating room to be a precedence over treatment passes.
  • Resident 44 stated drugs and meals have been delayed due to a scarcity of employees.
  • An ombudsman said that the power was short-staffed.
  • A Grievance Grievance Report of Investigation documented short-staffing, delays of as much as an hour for name lights to be answered, and water not getting handed when the night time shift is short-staffed.
  • A Facility Evaluation Device dated January three, 2018 documented a ratio of 10 residents to at least one aide, however the Midnight Census Report documented two aides for 51 residents.
  • Resident 20 stated she had not been showered in three months and didn’t have her tooth brushed.  Two aides, each referred to as in early due to the absence of employees, confirmed at 1:42 P.M. that Resident 20’s hair had not been combed, her tooth had not been brushed, she was dirty, and she or he wanted help with consuming meals on the lunch tray, which had simply been delivered.
  • The wound care nurse stated Resident 20 developed Moisture Related Pores and skin Deterioration due to premature incontinence care.

As of December 18, 2018, CMS had not imposed a CMP or DPNA towards the power.  The power had a two-star score in staffing.

Status Submit-Acute & Rehab Middle McMinnville

The Might 18, 2018 grievance survey on the Oregon nursing facility cited seven deficiencies, together with two-harm-level deficiencies, incontinence care and staffing.  The harm-level deficiency (degree G) in staffing was based mostly on the next findings:

  • The power self-reported to the protecting providers company that Resident 2 was left in his/her wheelchair after having a bowel motion and his/her peri space was “red and excoriated.”  Resident 2’s member of the family was upset.  Though 5 CNAs have been scheduled to work on the night shift, one didn’t present up and one other left early.  As well as, the aides have been required to help with two new admissions.  The company licensed follow nurse (LPN) stated the previous administrator and staffing coordinator have been each conscious of the staffing scarcity, however didn’t present a alternative aide.
  • Six of eight residents who have been alert and oriented stated they needed to wait for name lights to be answered.
  • Resident council assembly notes indicated complaints about residents ready for lengthy durations of time for name lights to be answered.
  • The interim Director of Nursing Providers stated residents acquired drugs late due to the scarcity of aides.
  • Surveyors’ evaluate of the Direct Care Staffing Report discovered that between March 22 and April 22, 2018, “the facility did not maintain state minimum CNA staff ratios on thirteen occasions.”  As well as, “The payroll records revealed there were 184 occasions that Licensed Nurses and CNAs were unable to take rest or meal breaks.”

As of December 18, 2018, no DPNA or CMP had been imposed towards the power, which had been designated a Particular Focus Facility for greater than a yr.  It had a five-star score in staffing.

No Hurt-Deficiencies

The Middle checked out a number of no-harm staffing deficiencies in California, Ohio, and Illinois. 

Twin Oaks Submit Acute Rehab

The March 29, 2018 annual survey cited the California nursing facility with 12 no-harm deficiencies.  The 2567 describes the D-level, no-harm staffing deficiency at F725 as based mostly on the care of 5 of 49 sampled residents:

  • Resident 251 was not turned in the course of the night time.  He was moist all night time and had a painful rash within the morning.  When he requested for cream, he was advised to get in line.  His ache was 10 on a scale of 1-10.
  • Resident 254 has had episodes of incontinence due to ready for help.  Employees advised her to go in her mattress and they might clear her up later.
  • Resident 76 informed surveyors he waits for lengthy durations of time for drugs and for help going to the toilet.
  • Resident 250, admitted after hernia surgical procedure, advised surveyors she doesn’t get ache treatment in a well timed approach and is all the time in ache.
  • Resident 27 informed surveyors that she waits for lengthy durations of time for help in going to the toilet.

As of December 2018, the power had not had any CMPs of DPNAs imposed since 2017.It had a one-star score in staffing, with an icon.

Stow Glen Well being Care Middle

The January 18, 2018 annual survey cited the Ohio nursing facility with 25 deficiencies: one substantial compliance deficiency, 21 no-harm deficiencies, one harm-level deficiency (neglect associated to unrelieved ache), and one speedy jeopardy deficiency (an infection management).  The no-harm, F-level staffing deficiency at F725 was based mostly on the care of 11 residents (of 78 residents within the facility):

  • Resident 125, who needed to be shaved, had not been shaved for a number of days and had a heavy progress of facial care. 
  • Resident council minutes from a number of conferences indicated that employees weren’t obtainable to help residents once they have been wanted; that employees didn’t reply name bells well timed; that residents waited in mattress for wound care and showers; and that residents complained of “unresolved grievances related to staffing.”
  • Resident 55 stated she was bladder incontinent and never taken to the toilet as wanted; she additionally complained about chilly meals.
  • Resident 5 informed surveyors about chilly meals.
  • The Dietary Supervisor informed surveyors that meals was chilly as a result of the power didn’t have sufficient employees to move trays.

As of December 18, 2018, the power had not had any CMPs imposed since 2016.It had a three-star score in staffing.

Symphony of Bronzeville

The grievance survey on Might 11, 2018 cited the Illinois nursing facility with 12 no-harm deficiencies.The D-level deficiency for F725 was based mostly on the next surveyor findings for one among 4 residents reviewed:

  • Resident 25 was incontinent of bowel and bladder.  The Director of Nursing indicated that incontinent residents ought to be modified each two hours – 4 modifications per shift. 
  • On Might 1, 2018, at 11:55 A.M., Resident 25 indicated to the surveyor that she was moist.  At 12:30 P.M., the aide confirmed that Resident 25’s incontinence temporary was soaked, her sheet was soaking moist, and there was a “large wet stain . . . visible on the blue mattress.” 
  • On Might three, at 1:50 P.m., Resident 25 was soaking moist.  The aide confirmed that Resident 25’s incontinence temporary appeared prefer it had not been modified in a number of hours.
  • On Might eight, an aide for Resident 25 on the 7:00 A.M. to three:00 P.M. shift informed surveyors that she often has 13-16 residents to care for, 13 of whom are “total care.”  Three of the residents are “mechanical lift,” which signifies that she should attempt to discover one other aide to assist her.  She can also be assigned to the day room 3 times per shift, half an hour every time.
  • The employees coordinator scheduler indicated that there ought to be seven aides for the 78 residents on the second flooring on the 7:00 A.M. to three:00 P.M. shift, however that there are often solely 5 or 6 aides.  She described the power as short-staffed.
  • A surveyor’s evaluation of residents’ degree of care discovered 76 residents on the second flooring, 48 of whom are “total care/extensive assist.”
  • The Every day Task Sheet documented 5 or 6 aides on the 7:00 A. M. to three:00 P.M. shift on Might 1-Four, 2018.

As of December 18, 2018, CMS had not imposed any CMPs towards the power within the prior three years.The power had a one-star score in staffing.

Abstract of Findings

First, the Facilities for Medicare & Medicaid Providers cited comparatively few nurse staffing deficiencies – 781 amenities out of roughly 14,00zero amenities nationwide.Since most amenities shouldn’t have sufficient employees to completely meet residents’ wants, the .5% quotation price is extraordinarily low.

Second, CMS categorized the overwhelming majority of staffing deficiencies as no-harm: 758 deficiencies (96.eight%) have been referred to as no-harm; solely 23 of the deficiencies have been referred to as instant jeopardy (17 deficiencies) or precise hurt (6 deficiencies).So-called no-harm deficiencies[3] included residents’ complaining of unrelieved ache and never receiving ache medicine and residents’ not receiving continence care and being left soaking moist for hours.

Third, CMS imposed few cures on even the small variety of amenities whose deficiencies it referred to as precise hurt or fast jeopardy.Solely two amenities with a direct jeopardy staffing deficiency had a CMP of greater than $100,00zero.Greater than half of the amenities cited with jeopardy or harm-level deficiencies had no enforcement motion imposed in any respect.

The federal survey stories have been comparable to one another, whether or not the staffing deficiency was cited as quick jeopardy or no-harm.Surveyors comply with the federal survey protocol that directs them in how one can determine and cite deficiencies.However, and despite the fact that the Middle reviewed solely a small variety of survey studies, what’s most putting is how comparable the proof seems within the survey stories.Surveyors describe the failures of care by way of a number of examples of: poor resident outcomes, resident complaints about inadequate staffing, employees admissions that the power is just not adequately staffed to satisfy residents’ wants, and documentation from facility data that the power doesn’t have sufficient employees (based on its personal staffing requirements).Surveyors appeared extra more likely to cite quick jeopardy in staffing once they cited further jeopardy-level deficiencies.In these instances, they included further particulars concerning the staffing deficiency.Nevertheless, as a basic matter, the proof that surveyors cite seems to be the identical, whether or not the deficiency is known as jeopardy or no-harm.

Dialogue and Suggestions

The federal oversight system for nursing amenities, documented by these knowledge, is failing residents.Whereas recording that residents are affected by egregiously poor care, the regulatory system fails to take critical (or, typically, any) enforcement motion towards the amenities.

CMS must act extra decisively to guard residents and to make sure that the mandate of the Nursing Residence Reform Regulation is met – that every resident receives the care and providers she or he must “attain and maintain their highest practicable physical, mental, and psychosocial well-being.”

The Middle recommends that CMS take instant motion to strengthen the oversight system.CMS ought to:

  • Revise the Lengthy Time period Care Survey Course of (LTCSP) Process Information and surveyor steerage (Appendix PP of the State Operations Guide) to require that surveyors think about citing a staffing deficiency each time they cite any high quality of care deficiency.
  • Revise the star score system to offer that a facility with an precise hurt or speedy jeopardy staffing deficiency obtain a one-star score in staffing, with a singular new icon indicating the harm-level or jeopardy deficiency in staffing.
  • Revise Chapter 7 of the State Operations Guide (Survey and Enforcement Course of) to impose significant, complete, and efficient sanctions towards amenities that fail to make use of adequate employees, with growing sanctions for repeated or uncorrected staffing deficiencies.  The monetary prices of sanctions ought to exceed the prices of offering enough employees.  The regulatory system ought to present that noncompliance is extra pricey to amenities than full compliance. 

CMS ought to impose cures instantly towards amenities with staffing deficiencies; it shouldn’t present amenities with a chance to right staffing deficiencies.

Applicable sanctions ought to embrace:

  • Per day CMPs for every day that a facility lacks enough nursing employees.
  • Directed plans of correction that require amenities to rent everlasting nursing employees (specifying numbers and classes of employees and shifts).
  • Obligatory DPNA till a facility demonstrates that it has achieved applicable nurse staffing ranges for a one-month interval.
  • Obligatory ban on conducting a nurse aide coaching and competency analysis program.
  • For repeated or uncorrected staffing deficiencies, denial of cost for all Medicare and Medicaid residents, screens, and short-term administration.

Jan. eight, 2019, T. Edelman.