Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a 21-day period. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on February 2, 2025. Additionally, the evening shift ratio of one NA per eleven residents was not met on December 24 and 25, 2024. Furthermore, the night shift ratio of one NA per fifteen residents was not adhered to on December 25, 2024, January 5, 6, 7, and 11, 2025, and February 1 and 2, 2025. These deficiencies were identified through a review of nursing schedules, indicating a pattern of non-compliance with staffing regulations.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.