Consistent Understaffing of Nurse Aides
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides across multiple shifts, as evidenced by a review of nursing time schedules and interviews with staff. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility consistently fell short of these requirements over a series of 59 out of 63 shifts reviewed. On several specific dates, the facility's census data indicated a need for a certain number of nurse aides based on the number of residents. For instance, on September 1, 2024, with a census of 191 residents, the facility required 19.10 nurse aides during the day shift but only provided 16.39. Similarly, on the night shift of the same day, 12.73 nurse aides were needed, but only 10.61 were available. This pattern of understaffing was repeated on numerous other dates, including September 2, 3, 4, and 5, 2024, where the number of nurse aides fell short of the required numbers for both day and night shifts. The deficiency was not limited to a single period but was observed over several months, including May, September, and December 2024. On December 15, 2024, for example, the facility had a census of 183 residents, requiring 18.30 nurse aides during the day shift, but only 14.00 were provided. The consistent lack of adequate staffing levels indicates a systemic issue in meeting the regulatory requirements for nurse aide staffing, with no additional higher-level staff available to compensate for the deficiencies.
Plan Of Correction
There were no adverse effects to the residents in the center as a result of the CNA ratios for the night shift staffing during the months of May, September or December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a CNAs per 10 residents on day shift, 11 residents on evening shift, and 15 residents on night shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.