Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 17 out of 19 days reviewed. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility consistently fell short of these requirements across multiple shifts and dates, as evidenced by the review of nursing staff schedules, punch reports, and interviews with staff. On July 1, 2024, the facility had a census of 92 residents, necessitating 69 hours of nurse aide care during the day shift, 62.73 hours during the evening shift, and 46 hours overnight. The facility only provided 60, 42, and 37.5 hours of care, respectively, with no additional higher-level staff available to compensate for the deficiency. Similar shortfalls were observed on subsequent days, with the facility repeatedly failing to meet the required hours of nurse aide care based on the census data. The deficiency persisted over several months, with specific instances noted on September 28 and 29, October 1 to 4, and February 3 to 9, 2025. Each of these dates showed a consistent pattern of understaffing, with the facility unable to provide the necessary hours of nurse aide care required by the resident census. The Nursing Home Administrator confirmed the failure to meet staffing ratios during a review on February 11, 2024.
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.