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P5520

Nurse Aide Staffing Deficiency on Evening and Overnight Shifts

St Marys, Pennsylvania Survey Completed on 12-23-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required nurse aide (NA) staffing ratios for both the evening and overnight shifts on November 30, 2024. Specifically, during the evening shift, the facility had a census of 101 residents but only 8.05 NAs worked, whereas 9.18 were required to meet the regulation of one NA per 11 residents. Similarly, for the overnight shift, the facility had 6.37 NAs working when 6.73 were required to meet the regulation of one NA per 15 residents. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on December 23, 2024.

Plan Of Correction

1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels, staffing requirements, and any gaps. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional NA staff will be scheduled proactively, especially during peak times, holidays, or any days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels and staff ratios throughout the day and night shifts and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that staffing ratios are met. The Nursing Home Administrator will review staffing ratios against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.

See complete original report
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