Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. The regulation specifies a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. A review of the facility's staffing records revealed that on 35 out of 63 shifts reviewed, the facility did not provide the minimum required number of nurse aides. Specific dates were identified where the number of nurse aides fell short of the required ratios, with discrepancies noted across day, evening, and night shifts. The facility's census on the dates in question ranged from 94 to 99 residents, and the shortfall in staffing was not compensated by additional higher-level staff. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the staffing requirements on the specified dates. This deficiency was identified through a review of staffing records and staff interviews, highlighting a significant lapse in compliance with the staffing regulations set forth for long-term care facilities.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on dates and shifts identified. The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring. The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. Calculation of daily shift ratios will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the staffing ratio. If call-offs occur, all efforts will be made to attempt to fill that position. Daily ratios will be audited weekly for 4 weeks and then monthly for 2 months. Results will be forwarded to the QA committee monthly for review and recommendations.