Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two occasions, as evidenced by a review of staffing records and staff interviews. On January 3, 2025, during the evening shift, the facility had 6 nurse aides for a census of 76 residents, falling short of the required 6.91 nurse aides. Similarly, on January 5, 2025, during the day shift, the facility had 7.30 nurse aides for a census of 75 residents, which was below the required 7.50 nurse aides. On both dates, there were no additional higher-level staff available to compensate for the staffing deficiency, resulting in non-compliance with the regulation effective July 1, 2024, which mandates specific nurse aide to resident ratios for different shifts.
Plan Of Correction
The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. The facility is focusing on retaining current nursing staff. We have only 1 CNA opening at this time, so call offs have been the ongoing issue. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.