Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift. This deficiency was observed over several days, with complete absence of NAs on certain shifts, notably from July 28 to July 31, 2024, where no NAs were present during the day and evening shifts despite a census ranging from 77 to 79 residents. The review of staffing documents revealed consistent shortages across multiple time periods, including late December 2024 and late January 2025. The Nursing Home Administrator confirmed the facility's inability to provide the required staffing information and acknowledged the failure to meet the minimum NA ratio requirements. This deficiency was identified through a review of staffing documents and staff interviews, highlighting a significant lapse in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
The facility must maintain the minimum of one nursing assistant for every 10 residents during the day shift, a minimum of one nursing assistant for every 11 residents for the evening shift, and a minimum of one nursing assistant for every 15 residents for the overnight shift. To ensure that this regulatory requirement is met, the following action plan will be implemented: Education was provided to the scheduler on February 4, 2025, and will be provided to the Director of Nursing by the Administrator to ensure that they understand the regulatory staffing requirements for nursing assistants, as they are the two staff members who cover call-off scheduling on the off shifts and weekends. The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that nursing assistant ratios are met for all shifts. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting, and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.