Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides during the day, evening, and overnight shifts on several occasions. During the day shift, the facility was understaffed on three days, with the number of nurse aides falling short of the required ratio for the resident census. Similarly, during the evening shift, the facility did not meet the required staffing levels on four days. The most significant shortfall was observed during the overnight shift, where the facility failed to meet the required nurse aide-to-resident ratio on eleven days. The deficiency was identified through a review of nursing staffing hours and confirmed during an interview with the Nursing Home Administrator. The review covered specific periods in November and December 2024, revealing consistent understaffing across different shifts. The administrator acknowledged the failure to meet the regulatory requirements, confirming the findings of the surveyors. This deficiency indicates a pattern of inadequate staffing that could potentially impact the quality of care provided to residents.
Plan Of Correction
1. While the facility cannot retroactively correct; since the staffing citations, the facility has hired 2 CNAs. Also, the facility has seen a total of 2 CNAs come off of orientation in the last 2 weeks that will now be included in the facility's nurse aide ratio. 2. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the nurse aide to resident ratios. 3. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 4. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the nurse aide to resident ratios. 5. The Scheduling Manager/Designee will randomly audit the nurse aide to resident ratios weekly for 3 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly by the facility's QAPI Committee.