Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the daylight and night shifts over several days. Specifically, on three occasions, the facility did not provide the mandated one nurse aide per 10 residents during the daylight shift. Additionally, on 15 occasions, the facility did not meet the requirement of one nurse aide per 15 residents during the night shift. This deficiency was identified through a review of staffing documents and confirmed by the Nursing Home Administrator during an interview. The facility's staffing records from December 2024 to January 2025 showed discrepancies between the actual hours worked by nurse aides and the hours required to meet the staffing regulations.
Plan Of Correction
Review of CNA Staffing Ratios: The facility reviewed CNA staffing ratios for the following dates: Day Shifts: 12/22/24, 1/1/25, 1/19/25. Night Shifts: 12/17/24, 12/18/24, 12/21/24, 12/22/24, 12/23/24, 12/31/24, 1/3/25, 1/4/25, 1/5/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25. The review determined that no grievances were filed, or care affected due to staffing ratios. Expanded Review: Additional dates were reviewed to ensure that CNA staffing ratios were met and to confirm that care was not adversely impacted. Education on Staffing Ratios: The scheduling coordinator will be educated on the CNA staffing ratio requirements. Day Shift: Minimum of 1 CNA per 10 residents. Evening Shift: Minimum of 1 CNA per 11 residents. Night Shift: Minimum of 1 CNA per 15 residents. Monitoring and Audits: The NHA or designee will conduct audits of CNA staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.