Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the required NA-to-resident ratios on several occasions across different shifts. During the day shift, the facility was understaffed on two days, with fewer NAs working than required for the resident census. On November 5, 2024, with a census of 78 residents, only 6.86 NAs worked when 7.80 were required. Similarly, on December 1, 2024, with a census of 77 residents, 7.20 NAs worked when 7.70 were required. The evening and overnight shifts also experienced staffing shortages. On November 29, 2024, during the evening shift, the facility had a census of 76 residents but only 4.80 NAs worked when 6.91 were required. The overnight shift was particularly affected, with staffing shortages on 11 out of 21 days reviewed. For instance, on November 8, 2024, with a census of 76 residents, only 4.26 NAs worked when 5.07 were required. These deficiencies were confirmed during an interview with the Nursing Home Administrator on December 5, 2024.
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 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 to maintain 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 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, 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 shift, resulting in an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.