Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on the overnight shift for four specific dates. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply on 10/21/24, 10/25/24, 11/18/24, and 11/19/24. On these dates, the facility had a census of 58 to 59 residents, requiring approximately 3.87 to 3.93 NAs, but only 3.00 to 3.63 NAs were present. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the shortfall in staffing on the specified dates.
Plan Of Correction
1. The facility is unable to correct the nurse aide staffing ratios that were not met during the overnight shifts on 10/21/24, 10/25/24, 11/18/24 and 11/19/24 due to unplanned absences. However, we will educate all nurse aides on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will work to ensure that nurse aide ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing and HR Director/Scheduler on regulation P5520 to ensure nurse aide ratios are met every shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible for calling off duty personnel or for calling extra support staff to assist. 4. The Nursing Home Administrator will audit staffing daily for four weeks and then monthly for two months to ensure nurse aide ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations and frequency of audits. 5. The facility will conduct an Employee Retention survey from 12/27/2024 through 1/6/2025 to evaluate staffing concerns and reasons for call-offs. This will be done to prevent further call-off concerns meeting daily staffing ratios. 6. A DON/designee will ensure staffing levels meet direct care requirements and report to DON or Nursing Home Administrator every day with needs or call-offs.