Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 19 out of 21 days reviewed, as evidenced by a review of nursing schedules from December 9 through 29, 2024. Specifically, the facility did not maintain the minimum NA to resident ratio of one NA for ten residents during the day shift on 15 days, one NA for 11 residents during the evening shift on 18 days, and one NA for 15 residents during the night shift on 11 days. This deficiency was confirmed by the Director of Nursing during an interview on December 30, 2024.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility has attended job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. We are using recruitment lists to call area CNAs to consider joining our facility. We have reached out to Nurse Aide training institutions to determine their ability to staff ongoing Nurse Aide Training classes. The facility has introduced an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.