Staffing Deficiency in Nursing Services
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios across multiple shifts over a period of 21 days in January 2025. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift. This deficiency was identified through a review of nursing schedules, staffing information, and staff interviews. On several specific days, the facility's census data indicated a need for a certain number of NAs based on the number of residents, but the actual number of NAs scheduled fell short. For instance, on January 6, 2025, with a census of 156 residents, 15.60 NAs were required for the day shift, but only 12.59 NAs were available. Similar shortfalls were noted on other days, such as January 7, 10, 11, and 12, 2025, where the number of NAs scheduled was consistently below the required number based on the resident census. The deficiency was further compounded by the lack of additional higher-level staff to compensate for the shortfall in NA staffing. The Nursing Home Administrator confirmed during an interview on January 30, 2025, that the facility did not meet the required staffing ratios on the days in question. This failure to adhere to staffing regulations indicates a systemic issue in maintaining adequate staffing levels to meet the needs of the residents during the specified period.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing nurse aides to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meetings, discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in-house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor nurse aide hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.