TUCSON, AZ- PUEBLO SPRINGS REHABILITATION CENTER

Based on observations, staff interviews, and review of facility documentation and policy, the facility failed to ensure there was sufficient staff to meet the needs of residents. The average daily census was 69 residents. The deficient practice could result in residents’ needs not being met.

Findings include:

Review of the Facility Assessment, updated February 2022 included a purpose to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment would help make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility. Using a competency-based approach focused on ensuring that each resident was provided with care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.

According to the Assessment, the following staffing levels were required in order to meet the needs of the residents:

Registered Nurses (RNs): 1-2 for day shift, 1-2 for for evening shift and 1 for night shift;
Licensed Practical Nurses (LPNs): 3-4 for days, 2-3 for evenings, and 2-3 for nights.
Certified Nursing Assistants (CNAs): 7-9 for days, 7-9 for evenings, and 4-5 for nights.
Restorative CNAs: 2 full-time days.

Review of the daily staffing postings dated January 10, 2022 through February 10, 2022 revealed a census which ranged from 62 to 77 residents, with an average resident census of 69.

Review of the staffing information revealed staffing levels were less than the number required as indicated by the Facility Assessment, including:
RNs – 12 out of 31 day shifts; 5 out of 31 evening shifts; and 26 out of 31 night shifts.
LPNs – 14 out of 31 day shifts; 15 out of 31 evening shifts; and 8 out of 31 night shifts.
CNAs – 25 out of 31 day shifts; 29 out of 31 evening shifts; and 4 out of 31 night shifts.
RNAs – 22 out of 31 day shifts.

On March 30, 2023 at 12:33 p.m. an interview was conducted with the staffing coordinator (staff #83) who stated that she had been in the position for about a month. She stated that she tries to maintain a 1:12 ratio for the CNA staff to resident ratio. She stated that the higher the census, the more staff were needed. She stated the facility utilize agency staffing and that the agency staff are added to the staff postings. She stated that when there are no RNAs, therapy will pick up the services for that day. She stated that inadequate CNA staffing would result in longer waits for call lights to be answered, a slower meal pass, and/or no showers provided for residents. She stated that it would be a desperate day to have only 4 CNAs on the floor.

However, review of the staffing documentation conducted with staff #83 revealed there were less than 5 CNAs working either days or evenings on 7 out of 31 shifts.