Overnight Nurse Aide Staffing Shortage
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during the overnight shift on one of the 21 days reviewed. Specifically, on January 13, 2025, the facility had a census of 74 residents, which required 4.93 NAs to meet the mandated ratio of one NA per 15 residents. However, only 4.53 NAs were on duty, resulting in a staffing shortage. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 3, 2025, who acknowledged that the facility did not meet the minimum NA ratio for the specified date and shift.
Plan Of Correction
The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required nurse aide to resident ratios on all shifts. The facility will also utilize licensed staff when needed to fulfill the aide need. The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible for maintaining adequate nurse aide staffing and nurse aide staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The facility shall also utilize licensed staff to help fill the CNA openings when able. The Director of Nursing or designee will meet 5x per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets nurse aide ratios. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, asking licensed staff to stay, posting need, posting need with agencies, offering bonuses, and mandating when needed. The facility has ads posted on Indeed and recently increased our shift differential for nurse aides on second and third shifts, resulting in an increase in applications over the last six weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.