Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by regulations effective July 1, 2024. During the review period from December 26, 2024, to January 2, 2025, the facility did not maintain the minimum staffing levels for nurse aides across various shifts. Specifically, the day shift required one nurse aide per 10 residents, but the facility fell short on six out of eight days. Similarly, the evening shift required one nurse aide per 11 residents, but the facility did not meet this requirement on five out of eight days. The night shift, which required one nurse aide per 15 residents, was also understaffed on four out of eight days. The deficiency was confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator and Director of Nursing. The review highlighted specific days where the number of nurse aides scheduled was insufficient for the resident census. For instance, on December 31, 2024, during the day shift, only 5.56 nurse aides were scheduled for a census of 104 residents, whereas 10.40 nurse aides were required. This pattern of understaffing was consistent across the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels.
Plan Of Correction
The Facility is unable to correct past CNA ratios. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to actively recruit for open CNA positions using online systems, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased as an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open positions. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary CNA ratios. The DON/Designee will audit CNA ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.