Deficiencies in TB Testing and Nurse Aide Staffing
Penalty
Summary
The facility failed to ensure compliance with tuberculosis testing requirements for Employee 3, an Occupational Therapist, who was hired on October 28, 2024. The personnel file review revealed that Employee 3 provided evidence of a negative QuantiFERON Gold blood test dated December 20, 2023, but there was no evidence of any further testing, such as a one-step test, blood test, or chest x-ray, being completed prior to their employment. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 31, 2025. Additionally, the facility did not meet the required staffing levels for nurse aides during various shifts over a 21-day period. Specifically, the facility failed to provide the minimum number of nurse aides per resident during the day shift on three occasions, the evening shift on two occasions, and the overnight shift on nine occasions. For example, on December 29, 2024, the day shift had 10 nurse aides for a census of 115 residents, requiring 11.50 aides, and the night shift had 7.20 aides for a census of 115 residents, requiring 7.67 aides. These staffing deficiencies were identified through a review of nursing care hours and staff interviews.
Plan Of Correction
The facility cannot retroactively correct past Nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.