Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides during specific shifts, as mandated by the regulation effective July 1, 2024. During the review of nursing staffing hours for the periods of November 17-23, 2024, November 24-30, 2024, and December 13-19, 2024, it was found that on December 14, 2024, the day shift had 6.5 nurse aides for a resident census of 72, falling short of the required 7.2 nurse aides. On the evening shifts of November 23, 2024, and December 15, 2024, the facility had 5 and 6 nurse aides for resident censuses of 69 and 72, respectively, both below the required numbers of 6.27 and 6.55 nurse aides. Additionally, on the overnight shift of November 28, 2024, there were 4 nurse aides for a census of 71, whereas 4.73 nurse aides were required. These deficiencies were confirmed during an interview with the Nursing Home Administrator and Director of Nursing on December 19, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents. At the time of the finding, the ratios and total nursing hours for the current working schedule were reviewed, and no issues were noted. 2. The scheduler and RNs will be re-educated on the July 1, 2024 nurse aide ratios of 1:10 and the importance of monitoring staffing as the day and/or shift progress. Education will be completed by the Director of Nursing and/or designee. 3. The Director of Nursing and/or designee will audit the current CNA working schedule, and the deployment sheets prior to the day and after the day is complete to ensure compliance. 4. Audits will be completed 3 times per week for one month, and weekly thereafter or until substantial compliance is achieved. Results will be reviewed in QAPI meeting. 5. Date of compliance is 1/20/2025.