Nurse Aide Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of nursing staffing documents and staff interviews. Specifically, the facility did not maintain the minimum required NA-to-resident ratios for the day, evening, and overnight shifts on several days. On the day shift, the facility was short of the required number of NAs on two days, with a census of 122 residents on one day and 120 residents on another, but only 10.28 and 9.28 NAs worked, respectively, when 12.20 and 12.0 were required. Similarly, the evening shift was understaffed on three days, with the facility failing to meet the required NA ratios. For instance, on one day with a census of 122 residents, only 9.15 NAs worked when 11.09 were required. The overnight shift also experienced staffing shortages on three days, with the facility not meeting the required NA ratios. On one occasion, with a census of 120 residents, only 7.78 NAs worked when 8.0 were required. The Assistant Director of Nursing confirmed these staffing deficiencies during an interview.
Plan Of Correction
1. Education will be provided to the Director of Nursing, Assistant Director of Nursing, and the Scheduler no later than 01/24/2025 on the regulatory requirements for Resident to Nursing Assistant Staffing Ratios. The facility is holding a 5-day-a-week Staffing Meeting and Quality Call to ensure compliance. 2. The nursing assistant schedule will be reviewed by the Director of Nursing, Assistant Director of Nursing, and Scheduler 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. 3. An audit will be conducted by the Director of Nursing and/or designee daily for 2 weeks, then 3 times a week for 2 weeks, then 2 times a week for one week then weekly ongoing, to ensure that nursing assistant ratios are met for the evening and overnight shifts. The audit will be monitored by the Director of Nursing or Designee. 4. The Director of Nursing will submit all Ratio Audits to the QAPI (Quality Assurance and Performance Improvement Committee) for review and recommendations at the monthly meeting.