Staffing Ratio Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 8 out of 21 days reviewed. Specifically, the facility did not meet the mandated ratios of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift. This deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. On several occasions, the facility's census data indicated a need for more nurse aide hours than were actually provided, with no additional higher-level staff available to compensate for the shortfall. The specific dates where staffing deficiencies occurred include July 4, 6, 7, and 8, 2024, as well as November 25, 27, 28, and 29, 2024. For instance, on July 4, 2024, the facility had a census of 79 residents, requiring 59.25 hours of nurse aide care during the day shift, but only 56.00 hours were provided. Similar discrepancies were noted on other dates, with the facility consistently failing to meet the required staffing levels. The Nursing Home Administrator confirmed these findings during a review of the staffing calculations and schedules.
Plan Of Correction
1. Facility to ensure that nurse's aide ratios are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of staffing schedules from 2/22/25-2/28/25 to verify nurse aide ratios each shift. If discrepancies are identified, regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week involving all three shifts for 4 weeks, and then 2 days per month involving all three shifts for 2 months to ensure that nurse aide ratios are consistent with regulatory requirements. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.