Inadequate Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on multiple occasions, as evidenced by a review of the facility's weekly staffing records. Specifically, the facility did not provide the minimum number of nurse aides per resident during the day, evening, and night shifts on 35 out of 42 shifts reviewed. For instance, on November 25, 2024, the day shift had only 5.20 nurse aides instead of the required 7.70 for a census of 77 residents. Similarly, on December 20, 2024, the night shift had only 3.13 nurse aides instead of the required 5.27 for a census of 79 residents. These deficiencies were consistent across several dates, indicating a pattern of inadequate staffing. The report highlights that no additional higher-level staff were available to compensate for the staffing deficiencies on the mentioned dates. An interview with the Nursing Home Administrator confirmed that the facility did not meet the required nurse aide to resident ratios on these occasions. The lack of sufficient nurse aide staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks resulting from this deficiency.
Plan Of Correction
Facility cannot retroactively correct past CNA to resident ratios. The facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A corporate team has been identified to assist with recruiting efforts for nursing positions. The scheduler has been educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. The facility acquired the OnShift platform for scheduling. The application alerts the scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so corrections, additions, etc. can be made to meet minimum requirements. Daily ratios will be audited weekly for 4 weeks, then monthly for 2 months. Audits will be reviewed at QAPI for compliance.