Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on seven out of twenty-one days reviewed. Specifically, the facility did not meet the mandated ratios of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift. This deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. On several occasions, the facility's census data indicated a need for more nurse aide hours than were actually provided, and there were no additional higher-level staff available to compensate for these deficiencies. For instance, on October 20, 2024, the facility had a census of 88 residents, requiring 66.00 hours of nurse aide care during the day shift, but only 64.00 hours were provided. Similarly, on November 15, 2024, with a census of 102 residents, the evening shift required 69.55 hours of care, but only 68.00 hours were provided. These discrepancies were consistent across other dates, such as November 16, 17, and December 4, 7, and 8, 2024, where the facility consistently failed to meet the required staffing levels. The Nursing Home Administrator confirmed these findings during a review on December 10, 2024.
Plan Of Correction
Admin and DON will conduct random audits of resident charts, during those days identified as having fallen below required ratios, to ensure no negative outcomes in care. The Admin will conduct a random audit weekly to ensure facility is compliant with staffing ratios. Audit will be for x3 weeks. And monthly audit x4 months. Results will be reported to QAPI.