Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios for several shifts between November 24, 2024, and December 31, 2024. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility did not comply with these requirements for thirteen shifts out of the 42 shifts reviewed. This deficiency was identified through a review of nursing time schedules, resident census data, and staff interviews. On multiple occasions, the facility's staffing levels were below the required minimums. For instance, on November 24, 2024, with a census of 36 residents, only 3.0 nurse aides were available during the evening shift, whereas 3.6 were required. Similarly, on November 25, 2024, with a census of 35 residents, only 3.0 nurse aides were present during the evening shift, falling short of the 3.5 required. These staffing shortages were consistent across various shifts, including day, evening, and night shifts, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the minimum nurse aide staffing ratios during an interview on January 2, 2025. The report highlights that the facility did not have sufficient nurse aides to meet the regulatory requirements, and no excess higher-level staff were available to address the shortfall. This lack of adequate staffing was a recurring issue across the reviewed period, affecting the facility's ability to provide the required level of care to its residents.
Plan Of Correction
PA 5520 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. 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.