PEORIA, AZ- LAKE PLEASANT POST ACUTE REHABILITATION CENTER

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. This deficient practice resulted in residents’ needs not being met.

Findings include:

During the initial phase of the survey, 14 out of 35 residents and the state appointed ombudsman for the facility identified concerns of not having enough staff. Residents reported they waited up to 2 hours for call lights to be answered.

The residents interviewed stated the following:
3 stated They were unable to get care in the facility at night.
2 stated they were unable to find staff when they left their room on one night
2 stated staff had slow response to call lights
4 stated their medications were significantly delayed

Review of Resident Council meeting minutes detail the following reoccurring subjects of concern:
At the Resident council meeting held on May 8, 2022, residents brought up concerns of medications being given late, and that wait times for assistance at night are long.

During the meeting on July 27, 2022 residents discussed showers not being completed.

During the Resident council meeting held on August 10, 2022 slow call light response time concerns were discussed.

During the meeting on September 21, 2022, residents discussed concerns regarding slow 200 hall call light response times.

During the meeting on October 12 2022, they discussed call light responses and concerns that CNAs were answering lights without addressing issues at the time light is answered.

During the meeting held on November 15, 2022, they discussed resident’s having issues getting medications on time, and that call light response times were a concern due to registry staff.

Review of the Facility Assessment updated March, 2022, stated the average daily census ranges for the past year was 89 residents, fluctuating as low as 73, and as high as 100. The facility hires and staffs for an average census of 91. The assessment stated the approximate number of admissions on a monthly basis is 64 and discharges is 61. 

There was a discrepancy on the facility assessment that showed CNA’s were staffed on 3 shifts (6 AM-2 PM, 2PM-10PM, and 10PM-6AM). This was brought to the Clinical Resource Staff #114’s, attention on 1/25/23 at 1:03 PM. She stated the facility assessment is reviewed annually by Resources which should have been caught by her.

The Facility Assessment revealed the facility’s general approach to ensure sufficient staffing to meet the needs of residents included scheduling 7-10 certified nursing assistant staff members per day shift (6a-6p), and 7-9 CNA’s per night shift (6p-6a). This is equal to 84-120 hours during the day shift and 84-108 hours during the night shift.

A list of CNA staffing data that included the below days was reviewed with the staffing coordinator and DON. Per the staffing requirements of 9 CNAs day and 7 CNAs night given during the interview with the SC, the following days were not staffed adequately by CNAs:
12/23/22- 60 scheduled, 49.23 actual worked
12/27/22- 72 scheduled, 56.76 actual worked
1/1/23- 60 scheduled, 47.31 actual worked
1/2/23- 72 scheduled, 68.91 actual worked
1/3/23- 84 scheduled, 58.12 actual worked
1/9/23- 72 scheduled, 59.23 actual worked
1/13/23-60 scheduled, 54.49 actual worked
1/18/23- 72 scheduled, 51.05 actual worked

Clinical Resource Staff #118, Staffing Coordinator #21, Director of Nursing #113 were interviewed on 1/26/23 at 9:45 AM. DON and SC were asked why there was such a discrepancy between the scheduled hours/CNAs and the actual hours worked. They stated that the numbers did not reflect registry staff. SC was asked where the actual hours worked total came from on the staff postings, and she stated she calculated them herself. When asked if the staff posting and punch details included registry staff and hours, she stated they did.

When asked if the above list of days were adequately staffed, they stated that if those numbers were
accurate, they were not, but they would verify the numbers themselves. They were advised the numbers were pulled directly from their staff postings. They did not provide alternate staffing numbers.

During an interview with a CNA, Staff #97, on 1/25/23 at 11:19 AM, He stated he is typically responsible for 13-15 residents during his shift. He said that 2 shifts a week, he will not have enough time to complete his assignments and will put off completing charting when that occurs. He stated he is asked to either stay late, come in early, or work overtime two to three times a week. When asked about registry staff and if there are any concern, the CNA stated he is fine with registry staff, except there are times when they do not do any work.

During an interview on 1/26/23 at 1:20 PM with Staff #114 and Executive Director, Staff #112, they stated in June 2022, the CNA schedule was changed to 2 twelve hours shifts in order to better serve residents. They reiterated leadership and members of the interdisciplinary team are available to assist on the floor if needed. Staff #112 stated if a resident does not get the help they need, or see staff when they go looking, then that speaks to the work ethic of the staff, not that they are not staffed enough.