Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on several days, including December 26, 2024, January 1, 2025, January 5, 2025, January 9, 2025, and January 10, 2025, where the number of NAs on duty was below the required levels based on the facility's census data. On December 26, 2024, the facility had a census of 84 residents, requiring 5.60 NAs for the night shift, but only 4.55 NAs were available. Similarly, on January 1, 2025, with a census of 84, the evening shift required 7.64 NAs, but only 7.46 were present. On January 5, 2025, with a census of 87, the day shift required 8.70 NAs, but only 7.85 were available, and the night shift required 5.80 NAs, but only 5.44 were present. On January 9, 2025, with a census of 88, the day shift required 8.80 NAs, but only 8.00 were available, the evening shift required 8.00 NAs, but only 7.75 were present, and the night shift required 5.87 NAs, but only 5.54 were available. Finally, on January 10, 2025, with a census of 89, the night shift required 5.93 NAs, but only 4.73 were present. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on January 15, 2025.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed 5X per week X 4 weeks, then weekly X 4 weeks. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.