Failure to Meet Overnight Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios during the overnight shift for three consecutive days. On January 28, 2025, with a census of 117 residents, the facility required 7.80 nurse aides but only had 7.25 on duty. On January 29, 2025, with a census of 116 residents, 7.73 nurse aides were needed, but only 7.09 were present. Similarly, on January 30, 2025, with the same census of 116, 7.73 nurse aides were required, but only 7.17 were available. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the failure to meet the staffing requirements during an interview on January 31, 2025.
Plan Of Correction
1. The administrator and/or designee will conduct a review of the last 14-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews for least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call-offs, higher level nursing will staff fill, if possible, we ask for volunteers with bonuses, then in extreme case, we will mandate and will stop admissions. We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census. We have created a shift differential for evenings and night shifts and a weekend differential - this program is for all our nursing staff. We have increased our Registered Nurse Licensed Practical Nurse wages. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class thru an outside contractor to develop more Certified Nurse's Aide. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.