Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for nurse aides during both the day and overnight shifts. Specifically, on January 26, 2025, the facility did not provide the required minimum of one nurse aide per 10 residents during the day shift, having only 140.75 nurse aide hours instead of the needed 154.50 for a census of 206 residents. Additionally, the overnight shift on the same day was understaffed, with only 78.25 nurse aide hours provided instead of the required 104.00 for a census of 208 residents. This deficiency was confirmed during an interview with the Director of Nursing on January 30, 2025, who acknowledged the facility's failure to meet the staffing requirements. The review of the three-week nurse staffing schedules from January 7, 2025, through January 27, 2025, highlighted these staffing shortfalls.
Plan Of Correction
The Center continues to have retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, and split shifts. Employment advertisement will be placed in our local newspaper of the opportunities at the Center. We called unscheduled staff and contacted supplemental staffing to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. A nurse aid class is starting on 2/17/2025 that has 10 students participating. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure CNA ratios are being met on day and night shifts. Audit results will be reviewed with the QAPI Committee meeting monthly to determine the need for further audits.