Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of 21 shifts reviewed. Specifically, the facility did not provide the minimum number of nurse aides needed for the evening and night shifts on several dates in December 2024. For instance, on December 3, 2024, the facility had 19.53 nurse aides on the evening shift, whereas 19.91 were required for a census of 219 residents. Similar deficiencies were noted on subsequent days, with the number of nurse aides consistently falling short of the required ratios based on the facility's census. The deficiency was confirmed during an interview with the Nursing Home Administrator on January 3, 2025. The administrator acknowledged that the facility did not meet the mandated nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortfall in nurse aide staffing during these shifts.
Plan Of Correction
Step 1 Facility can't retroactively correct. Step 2 To identify other areas of concern, the facility reviewed 1 week's worth of schedules to review CNA staffing ratios. Step 3 To monitor and maintain ongoing compliance, the NHA/Designee will educate staff responsible for the nursing schedule related to the required CNA ratios. Step 4 To monitor and maintain ongoing compliance, the NHA/designee will audit the nursing schedule related to CNA staffing ratios 5x's/week for 2 weeks and then weekly for 4 weeks, and monthly for 3 months. The facility currently has a plan in place for recruitment and retention of nursing staff members (RNs, LPNs, CNAs). Sign-On and Referral Bonuses are being utilized. Incentives for shift pick up are in place as well as staffing agency. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.