Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as stipulated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per resident on six out of twenty-one reviewed shifts. The regulation mandates a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. However, on several dates in January 2025, the facility's staffing records showed a shortfall in the required number of nurse aides for the night and evening shifts, based on the facility's census. For instance, on January 5, 2025, the night shift had 6.30 nurse aides instead of the required 7.07 for a census of 106 residents. Similarly, on January 6, 2025, the evening shift had 9.07 nurse aides instead of the required 9.73 for a census of 107 residents. These deficiencies were confirmed during an interview with the Nursing Home Administrator on January 28, 2025. The report also noted that no additional higher-level staff were available to compensate for the staffing shortfall on the mentioned dates.
Plan Of Correction
The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum nurse aide to resident ratios on all shifts, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.