Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios across multiple shifts over several weeks. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. This deficiency was observed on numerous dates between November 2024 and January 2025, as evidenced by a review of the facility's nursing staffing documents and confirmed through staff interviews. The staffing shortages were significant, with the facility often having fewer NAs than required for the number of residents present. For instance, on several occasions, the facility had a census of over 100 residents but failed to provide the necessary number of NAs to meet the regulatory requirements. The Nursing Home Administrator acknowledged these staffing deficiencies during an interview, confirming the facility's failure to comply with the mandated NA ratios on the specified dates and shifts.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Nursing Aide ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Nurses aides, call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing(DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Nursing Aid Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews NA ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement(QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet NA needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.