Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from January 28, 2025, to February 6, 2025. On the day shift, the facility did not maintain the minimum requirement of one nurse aide per 10 residents on four separate days. Similarly, the evening shift was understaffed on two days, lacking the required one nurse aide per 11 residents. Additionally, the night shift did not meet the standard of one nurse aide per 15 residents on two occasions. These deficiencies were confirmed through a review of facility staffing data and a telephone interview with the Nursing Home Administrator on February 11, 2025.
Plan Of Correction
Nursing Home Administrator/Designee will continue to audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing Home Administrator/Designee will utilize the Staffing Calculator Tool Spreadsheet to calculate these staff ratios to ensure compliance. Nursing Home Administrator, Director of Nursing, and Scheduler/HR will continue to hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Facility will hold bi-weekly meetings with cooperate recruiting team to improve hiring process and discuss opportunities to contract with additional Staffing Agencies to ensure the facility remains in continued compliance with nurse staff ratios and PPD. Nursing Home Administrator will continue to have daily staffing meetings with Director of Nursing and Facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it effects facility ratios. Nursing Home Administrator will continue to audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months utilizing the Staffing Calculator Tool Spreadsheet. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.