Staffing Ratio Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides during the day, evening, and overnight shifts on June 29 and 30, 2024. On June 29, the facility had a census of 94 residents, necessitating 58.75 hours of nurse aide care during the evening shift. However, only 43.00 hours of care were provided, with no additional higher-level staff available to compensate for the shortfall. Similarly, on June 30, the facility had a census of 93 residents, requiring 58.13 hours of nurse aide care during both the day and evening shifts. The facility only provided 37.50 hours of care for each of these shifts, again without any higher-level staff to make up for the deficiency. The deficiency was confirmed during a review of staffing calculations, nursing staff schedules, and punch reports with the Nursing Home Administrator on February 11, 2024. The administrator acknowledged that the required staffing ratios were not met on the specified dates. The report does not mention any corrective actions or follow-up measures taken to address the staffing shortfall.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.