Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on several occasions, as evidenced by document review and staff interviews. Specifically, the facility did not maintain the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on multiple days across December 2024, January 2025, and February 2025. For instance, on December 27, 2024, the day shift had 15 NAs for 169 residents, falling short of the required 16.9 NAs. Similarly, on January 18, 2025, the night shift had only 6 NAs for 171 residents, whereas the minimum required was 11.27 NAs. During an interview with the Nursing Home Administrator and Director of Nursing on February 12, 2025, it was revealed that the facility did not intentionally staff below the minimum requirements. However, they experienced challenges in maintaining staffing levels due to call outs caused by inclement weather and illness, which resulted in unfilled open slots. This situation led to the facility's inability to meet the regulatory staffing requirements on the specified dates.
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.