Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the daylight and evening shifts over a specified period. On two days, the facility did not provide the mandated one nurse aide per 10 residents during the daylight shift, and on three days, it did not meet the requirement of one nurse aide per 11 residents during the evening shift. Specifically, on 11/29/24 and 12/2/24, the daylight shift was understaffed, with actual hours worked falling short of the required hours. Similarly, on 11/29/24, 12/2/24, and 12/3/24, the evening shift also experienced a shortfall in staffing hours. The Nursing Home Administrator confirmed these deficiencies during an interview.
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 following dates: 11/29/24, 12/2/24 & 12/3/24. 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 platforms to attract new hires. 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 facilities 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 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: 12/16/2024