Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on three days, one NA per 11 residents during the evening shift on four days, and one NA per 15 residents during the night shift on three days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements on the specified shifts.
Plan Of Correction
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the daylight shift on three of seven days (1/20/25 through 1/23/25), one NA per 11 residents on the second shift on four of seven days (1/20/25, 1/21/25, 1/22/25, and 1/24/25), and one NA per 15 residents on the night shift on three of seven days (1/20/25 through 1/23/25) as required. 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on the evening shift, and 1:15 on night shift are met. Open positions will continue to be posted on various platforms including CCAC to attract new hires. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We increased bonuses as incentive to pick up shifts. We utilize agency to fill needed shifts. We added a $2.00/hr shift differential for Nurse Aides on the evening shift. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet ratios fall below required ratios due to call offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call our off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 2/24/2025