Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for nurse aides (NAs) across multiple shifts from November 29 to December 5, 2024. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts. For instance, on November 29, 2024, the day shift had 79 residents but only 7.13 NAs, falling short of the required 7.9 NAs. Similar deficiencies were noted on subsequent days, with the number of NAs consistently below the required ratios for the resident census. The deficiency was identified through a review of staffing documents and staff interviews, which revealed that the facility did not comply with the staffing regulations effective July 1, 2024. The facility's failure to maintain the required staffing levels was consistent across several days and shifts, indicating a systemic issue in meeting the regulatory requirements for nurse aide staffing ratios.
Plan Of Correction
Staffing ratios cannot be corrected for dates as this is a past occurrence and the facility needs to hire more CNA's to meet the staffing ratio regulation. Calculations of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler, ADON and/or DON while the facility is recruiting more CNA staff to meet the ratios. The facility continues to put effort into recruitment and retention of CNA staff members. This includes pickup shift bonuses for all staff pickups effective 6/29/24 and continues to present, new hire incentives ongoing, such as sign-on bonus and facility has revised and rolled out new wage scales for CNA staff effective November 2024. The facility has also initiated recruitment bonuses to staff that contribute to the recruitment of new CNA hires effective in November 2024. On 7/28/24, the facility initiated 8hr CNA shifts, from 7.5hr CNA shifts. The facility initiated utilizing licensed nursing staff, including floor and management staff to fill CNA holes. An additional Emergency Staffing Nursing Manager on Duty was initiated for weekend coverage, every weekend. Staff have been reeducated on staffing ratios and potential for mandation due to call off coverage at nurse staff meetings held on July 24th and July 25th, as well as additional meetings with RN supervisors on 11/20/24. The facility has hired individuals to attend CNA training in January and the facility plans to continue to hold CNA training classes on campus until CNA staffing needs are met. CNA ratios will be audited by the scheduler and DON/Designee daily for 11 weeks or until substantial compliance is achieved. The results will be reported monthly at the facility's Quality Assurance Performance Improvement Meeting.