Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a 10-day period from January 6, 2025, to January 16, 2025. The regulation mandates a minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. However, the facility did not comply with these requirements on the day shifts of January 11 and January 12, 2025, and the night shift of January 15, 2025. This deficiency was identified through a review of the facility's staffing data and was communicated to the Nursing Home Administrator (NHA) during a telephone conversation on January 17, 2025.
Plan Of Correction
1. CNA ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. Indeed employment ads will be posted. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed. 4. CNA ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week for 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee.