Staffing Deficiency on Daylight Shift
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the daylight shift on December 15, 2024. According to the staffing documents reviewed, the facility was required to provide one nurse aide per 10 residents, but on this particular day, the facility did not meet this requirement. The census for the day was 92 residents, necessitating 73.60 hours of nurse aide coverage, but only 64.00 hours were provided. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of the requirements under state and federal laws. The center recognizes the requirement of nursing assistants ratios of 1 to 10 on daylight, 1 to 11 on evening shifts and 1 to 15 on night shifts. The Director of Nursing/Designee will review documentation for the date 12/15/24 to ensure no adverse events occurred. To prevent recurrence, the scheduler and Director of Nursing will be re-educated by the administrator on the PA state requirements for nursing ratios and HPPD. The Administrator/Director of Nursing/Designee and scheduler will meet to review staffing ratios for the day as well as staffing projections through the week and weekends. The Director of Nursing is the backup for the scheduler. To monitor and maintain ongoing compliance, the Administrator/Designee will conduct weekly audits x 4 weeks to ensure nursing assistants ratios are met using the facility staffing tool. Findings of the audits will be reviewed at the facility's monthly QAPI meeting.