Staffing Ratio Deficiency at Warren Manor
Penalty
Summary
Warren Manor failed to meet the required nurse aide (NA) staffing ratios as per the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. On December 15, 2024, the facility did not have the mandated minimum of one NA per 10 residents during the day shift, with only 9.06 NAs working when 10.20 were required for a census of 102 residents. Additionally, the overnight shift on the same day did not meet the requirement of one NA per 15 residents, with 6.35 NAs working when 6.80 were needed. This deficiency was confirmed by the Nursing Home Administrator during an interview on December 23, 2024.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Warren Manor will be protected from future staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings, and 1:15 nurse aide for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing/Designee. The Director of Nursing/designee will review the monthly schedule prior to its start date to review for adequate staffing and fill in missing shifts before giving to the staff. The nursing scheduler/designee will review projected staffing levels with the Director of Nursing/designee daily to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Charge Nurses will be educated on appropriate staffing ratios by Director of Nursing/designee by 1/31/25 to immediately contact Director of Nursing for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution. Warren Manor will continue to aggressively advertise externally for the recruitment of nursing/nurse aide applicants to enhance current staffing levels. The facility will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Warren Manor is an approved provider of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. The facility offers extra incentives to current staff to cover extra shifts. A weekly recruiting meeting is held to address open positions. Open walk-in interview sessions will be held weekly. Nurse aide ratios will be reviewed by Director of Nursing/nursing designee 3x's a week for a month, then weekly x3 weeks, then monthly x2 months. Results will be reported at the monthly Quality Assurance and Process Improvement committee meeting.