Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum number of nurse aides required for the day, evening, and night shifts on several dates in December 2024. For the day shift, the facility was consistently short of the required 10.20 nurse aides for a census of 102 residents, with staffing levels ranging from 7.28 to 9.66 nurse aides. Similarly, the evening shift was understaffed on several occasions, with the number of nurse aides falling short of the required 9.27 to 9.36 for a census of 102 to 103 residents. The night shift also experienced deficiencies, with staffing levels below the required 6.67 to 6.87 nurse aides for a census of 100 to 103 residents. The Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was identified during a review of the facility's weekly staffing records and was corroborated by staff interviews, highlighting a systemic issue in maintaining the mandated staffing levels necessary for resident care.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.