Nurse Aide Staffing Shortages
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per resident during various shifts over a 14-day period. On the day shift, there were shortages on two days, with the census requiring more nurse aides than were present. Similarly, the evening shift experienced shortages on two days, and the night shift had shortages on three days. These deficiencies were confirmed by the Nursing Home Administrator and Director of Nursing during an interview, and there were no additional higher-level staff available to compensate for these shortages.
Plan Of Correction
A follow-up review was completed on 12/27/2024 for NA ratio numbers. 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, split shifts, extra day pay. All unscheduled staff were contacted, and supplemental staffing were contacted 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. There were no negative outcomes to residents. 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. Re-education will be conducted by the NHA/designee to the new Human Resource Director on calculating Ratios. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program is being 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 all shifts. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.