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 the regulation effective July 1, 2024. A review of nursing schedules for the period from December 27, 2024, to January 2, 2025, and January 9, 2025, to January 15, 2025, revealed that the facility did not maintain the minimum staffing levels on several occasions. Specifically, the day shift (7:00 a.m. to 3:00 p.m.) was understaffed on January 9, 11, 12, 13, 14, and 15, 2025, failing to provide one NA per ten residents. The evening shift (3:00 p.m. to 11:00 p.m.) on January 9, 2025, did not meet the required one NA per eleven residents. Additionally, the night shift (11:00 p.m. to 7:00 a.m.) was below the required one NA per fifteen residents on December 31, 2024, and January 9, 10, 11, 12, 13, and 15, 2025. These deficiencies were identified based on a review of the nursing time schedules, indicating a failure to comply with the staffing regulations over eight of the fourteen days reviewed.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected CNA ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.