Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per resident during various shifts over a 21-day period. During the day shift, the facility was short of the required one nurse aide per 10 residents on 13 days. The evening shift was understaffed with one nurse aide per 11 residents on 17 days, and the night shift was short of the required one nurse aide per 15 residents on four days. This deficiency was confirmed through a review of nursing time schedules and staff interviews. The Nursing Home Administrator acknowledged the staffing shortages during an interview on January 16, 2025. The facility did not have additional higher-level staff to compensate for the deficiency in nurse aide staffing. The specific dates of non-compliance were documented, highlighting the facility's failure to adhere to the staffing requirements set forth in the regulation. No additional information about the impact on residents or specific incidents resulting from the staffing shortages was provided in the report.
Plan Of Correction
The facility will continue to maintain the required nurse aide ratio of 1-10; 1-11; and 1-15. To increase staffing, the facility will call in off-duty staff, call sister facilities, or utilize agency staff as needed. Additionally, the facility will acquire new agency partnerships and offer bonuses to current staff to ensure sufficient nursing staffing. The RDCS educated the NHA/DON/scheduler on the required 1-10; 1-11; and 1-15 nurse aide ratio requirements, ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily for 5x weekly for 4 weeks, then 1x daily for 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.