Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from December 30, 2024, through January 8, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents on the day shift for ten days, one nurse aide per 11 residents on the evening shift for four days, and one nurse aide per 15 residents on the night shift for one day. These deficiencies were identified through a review of facility staffing data and were confirmed with the Nursing Home Administrator during a telephone interview on January 16, 2025.
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 for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed. Date of compliance for this case: Monday, March 17th, 2025.