Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts from January 23 to January 29, 2025. Specifically, the night shifts on January 23, 24, 25, 26, 27, and 29 did not have enough NAs to meet the required ratios for the number of residents present. For instance, on January 23, there were 188 residents but only 10 NAs, falling short of the required ratio of 12.53. Similarly, on January 24, there were 192 residents with only 9 NAs, not meeting the required ratio of 12.80. The evening shift on January 26 also failed to meet the required ratio, with 188 residents and only 16.40 NAs, instead of the required 17.09. The deficiency was confirmed during an electronic communication with the Nursing Home Administrator on January 31, 2025. It was acknowledged that the facility had not met the staffing requirements and that there were 30 vacant NA positions. The facility was attempting to address these vacancies by utilizing multiple agencies to fill the gaps. However, despite these efforts, the staffing levels remained below the mandated minimums, leading to the deficiency noted in the report.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.