Staffing and Medication Management Deficiencies
Penalty
Summary
The facility was found to have deficiencies in nursing services, specifically in maintaining the required nurse aide-to-resident ratios during various shifts. The report highlights that for 15 out of 21 days reviewed, the facility did not meet the minimum requirement of one nurse aide per 10 residents during the day shift. Similarly, the evening shift was understaffed for eight out of 21 days, failing to meet the one nurse aide per 11 residents requirement. The overnight shift was also deficient, with 17 out of 21 days not meeting the one nurse aide per 15 residents standard. These findings were confirmed through a review of nursing care hours and staff interviews. Additionally, the report notes a specific incident involving Resident 110, where there was no evidence of the disposition of the resident's medications upon their death. This was confirmed during an interview with the Nursing Home Administrator. The lack of documentation regarding the handling of medications post-mortem indicates a lapse in the facility's procedures for managing resident medications, contributing to the overall deficiencies identified in the report.
Plan Of Correction
1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.