Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on eight out of 21 shifts reviewed. Specifically, on December 23, 24, 25, 26, and 27, 2024, the facility did not provide the minimum number of nurse aides needed for the evening and night shifts based on the census. For instance, on December 23, 2024, there were only 8.33 nurse aides on the evening shift when 9 were required for a census of 99. Similarly, on December 24, 2024, the night shift had only 5.03 nurse aides instead of the required 6.67 for a census of 100. The deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged the shortfall in meeting the required staffing ratios. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. The facility cannot retroactively correct nurse aide staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.