Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as per the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum NA ratio of one NA per 10 residents during the day shift on six occasions and one NA per 11 residents during the evening shift on two occasions within the review period from November 17, 2024, to December 7, 2024. On the day shift, the facility was short of the required number of NAs on November 17, 21, 29, 30, December 3, and 5, 2024, with the number of NAs working being less than required based on the resident census. Similarly, on the evening shift, the facility did not meet the required NA ratio on November 18 and 30, 2024. The Human Resource Manager/Scheduler confirmed these staffing shortages during an interview on December 11, 2024.
Plan Of Correction
There were no negative care impacts to any resident as a result of the identified concern. The daily per patient day (PPD) staffing numbers remained over the state minimum. The facility cannot retroactively correct this finding. Nursing leadership will be re-educated on the Pennsylvania licensed professional staffing requirements by the Director of nursing or designee. The Scheduler was re-educated on CNA ratios by the Nursing Home Administrator. The facility will continue to recruit their own staff and contract with various agencies to meet CNA ratios. The Director of nursing or Designee will audit staffing ratios five times per week for four weeks, then re-evaluate for need to increase or decrease monitoring to verify that all measures are being taken to meet licensed practical nurse staffing ratios. Audit findings will be submitted to the Quality Assurance and Performance Improvement Committee for further review and recommendations.