Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents overnight. This deficiency was observed over multiple days within the review period from November 18, 2024, to December 18, 2024. The facility's staffing documents revealed shortages on seven days for the day shift, eight days for the evening shift, and three days for the overnight shift. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required staffing ratios on the specified dates and shifts. The census data indicated that the number of NAs working was consistently below the required number based on the resident census, leading to the deficiency in staffing levels. This shortfall in staffing was documented through a review of the facility's nursing staffing documents and was corroborated by staff interviews.
Plan Of Correction
1. The facility cannot go back to correct identified days when the nurse aide ratio was less than required for each shift. No adverse outcomes when the nurse aide ratio was less than required per interviews with clients. 2. A daily staff hour/ratio worksheet will be utilized, which has the staff ratio calculator function on it. 3. Administrator/Director of Nursing will educate staffing coordinators and RN charge nurses the week of Jan 13th on: - How to use the daily staffing sheet with ratios - How to replace call offs when needed - Notifications to the appropriate Interdisciplinary Team members when staffing does not meet ratios 4. Daily staffing meeting will be implemented with the administrator/Director of Nursing/staffing coordinator or designee to review staffing and appropriate ratios. Minutes will be taken for each meeting. 5. Administration will review agency contracts to ensure they are up to date. 6. Ratio audit will be completed by Administrator or designee 5 days a week x 4 weeks then: - 3 days a week x 2 weeks then weekly thereafter 7. Audits will be taken to Quality Assurance and Performance Improvement Committee for review/discussion.