Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on multiple occasions, as evidenced by a review of nursing time schedules and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts on seven different days. For instance, on December 8, 2024, the daylight shift required 127.50 hours of nurse aide care, but only 103.19 hours were provided. Similarly, on January 19, 2025, the evening shift required 113.18 hours of nurse aide care, but only 93.80 hours were provided. These deficiencies were confirmed by the Nursing Home Administrator during an interview. The report highlights that the facility consistently failed to provide adequate nurse aide coverage across different shifts, impacting the care provided to residents. The census numbers on the days in question ranged from 158 to 170 residents, indicating a significant shortfall in staffing relative to the number of residents. This shortfall in staffing was not isolated to a single day or shift but occurred repeatedly over a span of several weeks, demonstrating a pattern of non-compliance with the staffing regulations effective from July 1, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide to resident ratios on 12/8/24, 12/10/24, 12/12/24, 1/19/25, 1/20/25, 1/24/25, and 2/1/25. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator/Designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. The facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.