Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts over a period of 21 days. During the day shift, the facility was short of the required nurse aide hours on nine days, with a consistent shortfall of 3.92 hours each day for a census of 106 residents. Similarly, the evening shift experienced a shortage on 13 days, with the required hours not met on multiple occasions. The night shift also faced deficiencies on 12 days, with significant discrepancies between the actual and required hours, particularly on days with a census of 107 residents. The nursing schedules and census information reviewed for specific weeks revealed these staffing shortages. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the facility's failure to provide the mandated minimum number of nurse aides on the specified days and shifts. This deficiency highlights a systemic issue in maintaining adequate staffing levels to meet regulatory requirements, impacting the facility's ability to provide consistent care to its residents.
Plan Of Correction
The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the cited dates. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.