APPENDIX F
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
INVESTIGATIVE PROTOCOL
NURSING SERVICES, SUFFICIENT STAFFING
Objectives
o To determine if the facility has sufficient nursing staff available to meet the residents needs.
o To determine if the facility has licensed registered nurses and licensed nursing staff available to provide and monitor the delivery of resident care.
Task 5C: Use:
NOTE: This protocol is not required during the standard survey, unless it is triggered in the event of care concerns/problems which may be associated with sufficiency of nursing staff. It is required to be completed for an extended survey.
This protocol is to be used when:
o Quality of care problems have been identified, such as: Residents not receiving the care and services to prevent pressure sore/ulcer(s), unintended weight loss and dehydration, and to prevent declines in their condition as described in their comprehensive plans of care, such as bathing, dressing, grooming, transferring, ambulation, toileting, and eating; and
o Complaints have been received from residents, families or other resident representatives concerning services, such as: Care not being provided, call lights not being answered in a timely fashion, and residents not being assisted to eat.
Procedures:
o Determine if the registered/licensed nursing staff are available to:
- Supervise and monitor the delivery of care by nursing assistants according to residents care plans:
- Assess resident condition changes;
- Monitor dining activities to identify concerns or changes in residents needs;
- Respond to nursing assistants requests for assistance;
- Correct inappropriate or unsafe nursing assistants techniques; and
- Identify training needs for the nursing assistants.
o If problems were identified with care plans/services not provided as needed by the resident, focus your discussion with supervisory staff on the situations which led to using the protocol: how do they assure that there are adequate staff to meet the needs of the residents; how do they assure that staff are knowledgeable about the needs of the residents and are capable of delivering the care as planned; how do they assure that staff are appropriately deployed to meet the needs of the residents; how do they provide orientation for new or temporary staff regarding the resident needs and the interventions to meet those needs; and how do they assure that staff are advised of changes in the care plan?
o Determine if nursing assistants and other nursing staff are knowledgeable regarding the residents care needs, such as: the provision of fluids and foods for residents who are unable to provide these services for themselves; the provision of turning, positioning and skin care for those residents identified at risk for pressure sore/ulcers; and the provision of incontinence care as needed;
o If necessary, review nursing assistant assignments in relation the care and or services the resident requires to meet his/her needs;
o In interview with resident, families and/or other resident representatives, inquire about the staffs response to requires for assistance, and the timeliness of call lights being answered; and
o Determine if the problems are facility-wide, cover all shifts or if they are limited to certain units or shifts, or days of the week. This can be based on information already gathered by the team with additional interviews of residents, families and staff, as necessary.
Task 6: Determination of Compliance:
NOTE: Meeting the State mandated staffing ratio, if any, does not preclude a deficiency of insufficient staff if the facility is not providing needed care and services to residents.
o Compliance with 42 CFR 483.30(a), F353, Sufficient Staff:
- The facility is compliant with this requirement if the facility has provided a sufficient number of licensed nurses and other nursing personnel to meet the needs of the residents on a twenty-four hour basis. If not, cite F353.