Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. On January 5, 2025, during the night shift, the facility had a census of 141 residents but only maintained a NA ratio of 5.84, falling short of the required 9.40. Similarly, on January 6, 2025, the day shift had a census of 141 residents with a NA ratio of 10.28, not meeting the required 14.10. The night shift on the same day also failed to meet the required ratio, with a NA ratio of 5.73 against the required 9.40. Further deficiencies were noted on January 10, 2025, during the evening shift, where the facility had a census of 140 residents and a NA ratio of 11.97, below the required 12.73. On January 11, 2025, the day shift had a census of 141 residents with a NA ratio of 13.16, not meeting the required 14.10. Additionally, the night shift on January 11, 2025, had a census of 142 residents with a NA ratio of 8.31, failing to meet the required 9.47. These findings indicate a consistent failure to maintain the mandated staffing levels across various shifts and days.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. All residents will continue to receive care in accordance with their plan of care and attending physicians orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily x 4 weeks then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.