Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 15 out of 21 days reviewed. 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 did not meet these requirements on multiple occasions, as evidenced by the review of nursing staff schedules, punch reports, and interviews with staff. On specific dates, such as July 14, 2024, the facility census was 114, necessitating 77.73 hours of nurse aides during the evening shift, but only 66.00 hours were provided. Similarly, on July 20, 2024, with a census of 123, the overnight shift required 61.50 hours of nurse aide care, yet only 37.50 hours were provided. These discrepancies were consistent across several other dates, indicating a pattern of insufficient staffing. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during a review of staffing calculations, nursing staff schedules, and staff punch reports. This acknowledgment highlights the facility's awareness of the deficiency in maintaining adequate nurse aide coverage as per the regulatory requirements.
Plan Of Correction
No specific residents were identified. No residents were negatively impacted by the CNA ratios. An audit was completed of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator has reviewed staff recruitment and retention initiatives and has communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit CNA ratios 3 times per week for 4 weeks, then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.