Staffing Deficiency Due to Call-Outs
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on specific shifts during the week of February 2 - 8, 2025. On February 2, the night shift had 59 residents but only 3.90 NAs, falling short of the required 3.93 NAs. On February 6, the day shift had 59 residents with only 5.40 NAs, below the required 5.90 NAs. On February 8, the day shift had 61 residents with 5.57 NAs, not meeting the required 6.10 NAs, and the night shift had 61 residents with only 2.52 NAs, significantly below the required 4.07 NAs. During an interview, the Nursing Home Administrator and Director of Nursing explained that the facility did not intentionally staff below the minimum requirements but faced challenges due to call-outs caused by inclement weather and illness, which prevented them from filling all open slots.
Plan Of Correction
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the ratios and replacement of staff if indicated. 3. A staffing ratio document will be completed daily by the scheduler and reviewed at morning meetings. The ratio document will be updated with any changes in the schedule and reviewed with the DON/Admin Nurse to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. An audit of the ratio document against the deployment sheet will be completed daily for 1 week, weekly for 2 weeks and then biweekly X 2 weeks. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.