Night Shift Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the night shift on 9 out of 21 days between November 22, 2024, and December 12, 2024. The regulation mandates a minimum of one nurse aide per 15 residents overnight, but the facility did not comply with this requirement on several occasions. For instance, on November 23, 2024, with a census of 42 residents, the facility required 2.80 nurse aides but only provided 2.28. Similarly, on November 24, 2024, with a census of 41, the facility required 2.73 nurse aides but only provided 2.16. These staffing shortages were consistent across multiple dates, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the staffing shortfalls during an interview on December 12, 2024. The facility's failure to provide the mandated number of nurse aides was evident in the review of nursing time schedules and deployment sheets. The report highlights specific dates and census numbers, illustrating the consistent inability to meet the required staffing levels, which directly led to the deficiency noted by the surveyors.
Plan Of Correction
The facility will correct the deficiency: the administrator educated the director of Nursing and the Staffing Coordinator on PA Code 211.12 as it relates to Staff to resident Ratios and Direct Nursing Care Hours for certified nurse aides for the following dates: 11/23, 11/24, 11/26, 11/27, 11/28, 11/29, 12/03, 12/08, and 12/12/2024. To prevent reoccurrence, the staffing coordinator will ensure that the correct number of NA's are scheduled for each shift (day, evening and night) utilizing the staffing ratio/PPD worksheet and review with the DON daily. The facility will utilize the on-call nursing staff to maintain nursing hours should the facility fall below nursing rations on the overnight shift with an RN within a 30-minute drive from the facility. The facility will continue weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external candidates, and offer referral bonuses to attract and retain staff. The facility will conduct audits by the DON/Designee/Scheduling Coordinator, who will review the worksheet daily for compliance for two weeks, then weekly for two weeks, and continue with weekly review and report quarterly thru QAPI.