Failure to Meet Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not maintain the minimum required NA-to-resident ratios on the day shift for four out of seven days reviewed, on the evening shift for two out of seven days, and on the night shift for one out of seven days. The specific dates of non-compliance were December 29, 2024, January 2, 3, and 4, 2025, for the day shift; December 31, 2024, and January 3, 2025, for the evening shift; and January 1, 2025, for the night shift. The facility's census and staffing ratio information revealed that on these dates, the NA ratios were below the required levels. For instance, on December 29, 2024, the day shift had a NA ratio of 12.0 instead of the required 12.30 for 123 residents. Similarly, on January 1, 2025, the night shift had a NA ratio of 7.0 instead of the required 8.47 for 127 residents. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required NA ratios during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected CNA ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.