Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of twenty-one reviewed shifts. Specifically, on January 30, 2025, the evening shift had 4.33 nurse aides instead of the required 4.36 for a census of 48, and the night shift had 2.97 nurse aides instead of the required 3.2. On January 31, 2025, the day shift had 4.13 nurse aides instead of the required 4.80, and the evening shift had 4.27 nurse aides instead of the required 4.36. Additionally, the evening shift on January 31, 2025, had 3.13 nurse aides instead of the required 3.20. On February 1, 2025, the day shift had 4.6 nurse aides instead of the required 4.7 for a census of 47. On February 3, 2025, the evening shift had 3.9 nurse aides instead of the required 4.27, and the night shift had 3 nurse aides instead of the required 3.13. Finally, on February 4, 2025, the night shift had 2.97 nurse aides instead of the required 3.27 for a census of 49. No additional higher-level staff were available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/ week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.