Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides as per the Commonwealth of Pennsylvania Long Term Care Licensure Regulations. Specifically, during the day shift, the facility did not provide the minimum required number of nurse aides for four out of the 21 days reviewed. On September 1, 2024, there were 4.17 nurse aides for a census of 51 residents, requiring 5.10 nurse aides. On November 24, 2024, there were 4.20 nurse aides for a census of 50 residents, requiring 5.00 nurse aides. On November 29, 2024, there were 4.67 nurse aides for a census of 50 residents, requiring 5.00 nurse aides. On January 18, 2025, there were 5.10 nurse aides for a census of 53 residents, requiring 5.30 nurse aides. Additionally, during the night shift on January 19, 2025, the facility provided 3.20 nurse aides for a census of 53 residents, requiring 3.53 nurse aides. These staffing deficiencies were identified through a review of nursing staff care hours and confirmed through staff interviews.
Plan Of Correction
- Residents were not found to be affected by deficient practice. - The Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for the past week to review NA staffing ratios. - The Director of Wellness and Scheduler will meet daily to review the schedule to ensure ratios and hours meet regulation. The Executive Director will reeducate the wellness team on efforts to improve recruitment and retention of direct care staff and the scheduling process, including critical shift incentives. - The Director of Wellness will conduct Quality Improvement (QI) monitoring of the nursing schedule related to NA staffing ratios 5 times a week for 2 weeks, then weekly for 2 weeks, and finally monthly for 2 months. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI).