Deficiency in Night Shift Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides during the night shift on five out of seven days in the week of December 15, 2024. Specifically, the facility did not ensure a minimum of one nurse aide per 20 residents. On December 15, 2024, with a census of 153 residents, only 70.49 nurse aide hours were provided, falling short of the required 76.5 hours. Similarly, on December 16, 2024, 71.6 nurse aide hours were provided for 153 residents, again below the required 76.5 hours. On December 17, 2024, 56.01 nurse aide hours were provided for 152 residents, whereas 76 hours were needed. On December 18, 2024, 69.43 nurse aide hours were provided for 153 residents, short of the 76.5 hours required. Lastly, on December 21, 2024, 69.2 nurse aide hours were provided for 155 residents, while 77.5 hours were necessary. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on December 23, 2024.
Plan Of Correction
Plan of Correction for § 211.12(f.1)(3) Nursing Services: 1. Review of CNA Staffing Ratios: The facility reviewed CNA staffing ratios for the following dates: - Day Shifts: 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/21/24. - Night Shifts: 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/21/24. The review determined that no grievances were filed, or care affected due to staffing ratios. 2. Expanded Review: Additional dates were reviewed to ensure that CNA staffing ratios were met and to confirm that care was not adversely impacted. 3. 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. 4. 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. 5. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.