Staffing Deficiency on Daylight Shift
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the daylight shift on November 29, 2024. Specifically, the facility did not provide the mandated one nurse aide per 12 residents, as evidenced by staffing documents and confirmed by the Nursing Home Administrator. On this date, the facility had a census of 47 residents but only provided 32.03 hours of nurse aide coverage, falling short of the required 37.60 hours. This deficiency was identified during a review of staffing documents covering the period from November 29, 2024, to December 3, 2024, and was confirmed in an interview with the Nursing Home Administrator on December 4, 2024.
Plan Of Correction
The facility failed to meet the CNA required ratios on one daylight shift, 11/29/2024, during the five-day period of 11/29/24 through 12/3/24. The state ratio regulation will be reviewed with the nurse scheduler and RNS. Ratios are reviewed daily by the DON when posting staffing sheets. Ratios are met at the time of scheduling. If there is a call off or no show, and the staffing ratios would not be met, the DON/designee will attempt to replace the call off or no show as follows: 1. Seek CNAs to volunteer from all qualified staff who are working. 2. Contact qualified employees who have made themselves available for overtime. 3. Attempt to contact employees on the next shift to come in early. 4. Use Per Diem Staff. 5. Use Temporary Staffing Agencies. In addition, the facility uses bonus incentives for internal staff, and we contract with 5 different nursing temporary agencies. The nurse scheduler will complete the DOH staffing ratio spreadsheet and turn it into NHA for review on a weekly basis. Information will be presented to the QAPI committee for review and recommendations.