Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts for specific days reviewed. Specifically, the facility did not ensure a minimum of one nurse aide per 11 residents during the evening shift on two occasions and one nurse aide per 15 residents during the overnight shift on three occasions. This deficiency was identified through a review of nursing staffing hours and staff interviews conducted during an onsite survey. The survey revealed discrepancies in the staffing calculations, as staff were recorded as providing more hours of care than their scheduled shifts, leading to incorrect staffing data. Despite multiple requests from the surveyor, the facility was unable to provide accurate nurse staffing information. The review of nursing care hours for specific dates confirmed the shortfall in nurse aide staffing, which was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing/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. Director of Nursing/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.