Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five occasions out of 21 shifts reviewed. Specifically, on January 20, 21, 22, and 23, 2025, the night shift was understaffed with only 2 nurse aides present, whereas the required number was slightly higher based on the census of 32 to 34 residents. Additionally, on January 25, 2025, the day shift was also understaffed with 3 nurse aides instead of the required 3.20 for a census of 32. There were no additional higher-level staff available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on January 27, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. We are continuing to use available resources provided including Indeed, Appolli, signing contracts with nursing agencies as needed. We are attending job fairs in the area. Wages remain competitive in the industry. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.