Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per residents during various shifts over a 14-day period. During the day shift, the facility was short on six days, with the number of nurse aides present ranging from 4.59 to 8.03, while the required number was between 8.1 and 8.5 based on the census. The evening shift was understaffed on four days, with the number of nurse aides present ranging from 6.03 to 7.0, while the required number was between 7.36 and 7.55. The night shift experienced the most significant shortages, with ten days of insufficient staffing, where the number of nurse aides present ranged from 4.2 to 5.4, while the required number was between 5.33 and 5.67. The Director of Nursing confirmed during an interview that the facility did not meet the minimum staffing requirements for nurse aides during the day, evening, and night shifts. There were no additional higher-level staff available to compensate for these deficiencies. The failure to provide adequate staffing levels was identified through a review of nursing time schedules and staff interviews, which highlighted the facility's inability to maintain the mandated nurse aide-to-resident ratios during the specified period.
Plan Of Correction
1. The facility cannot correct that the nurse aide ratio staffing was not met on 11/24/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, and 12/7/24. There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.