Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between January 8, 2025, and January 20, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on 10 out of 13 days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on nine days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified shifts. The report details the specific dates and the discrepancy between actual and required staffing hours, highlighting the facility's failure to comply with the staffing regulation effective July 1, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased nursing assistant staffing ratios for the days noted. Education will be provided by the Director of Nursing or designee to the scheduler and nursing supervisors on all shifts regarding the updated facility protocol and duties for filling call-offs and agency shift cancellations if nursing staff ratios drop below state minimum. The facility increased nurse aide hourly rates to recruit house staff, continues to focus on recruitment daily, and uses PRN agency staff to supplement open shifts. Staffing meetings will be held 5 days per week to review nursing assistant ratios for all shifts of the current and next day. Audits of nursing assistant ratios will be completed by the Nursing Home Administrator or designee weekly for 6 weeks to ensure the facility meets the state minimum staffing ratios. Results of the audits will be forwarded to our QAPI committee for review and recommendations.