Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 14 out of 57 shifts reviewed. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts according to the census on several dates in December 2024. For instance, on December 14, 2024, the day shift had 8.80 nurse aides instead of the required 10.5 for a census of 105, and the night shift had 6.00 nurse aides instead of the required 7.00. Similar deficiencies were noted on other dates, with the facility consistently falling short of the required staffing levels. The deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing shortfall, further exacerbating the issue.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 5. Date of compliance is January 21, 2025.