Facility Fails to Meet Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios across multiple shifts over a seven-day period. On the day shift of December 7, 2024, the facility had a census of 186 residents but did not meet the required NA ratio, having only 18.27 NAs instead of the required 18.60. Similarly, on the evening shift of December 9, 2024, with a census of 190 residents, the facility had an NA ratio of 16.07, falling short of the required 17.27 NAs. The most significant deficiency was observed on the overnight shifts from December 3 to December 9, 2024. Each night, the facility failed to meet the required NA ratios, with the census ranging from 180 to 190 residents. The NA ratios varied from 9.00 to 11.53, consistently below the required ratios, which ranged from 12.00 to 12.67 NAs. An interview with the Nursing Home Administrator confirmed that the facility was aware of not meeting the required NA ratios.
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.