Nurse Aide Staffing Shortages
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift on two occasions, one NA per 11 residents during the evening shift on one occasion, and one NA per 15 residents during the overnight shift on eight occasions. These deficiencies were identified through a review of the facility's nursing staffing documents covering specific periods in July, November, and December 2024. The Director of Nursing confirmed the staffing shortages during an interview, acknowledging the facility's failure to meet the minimum NA ratio requirements on the specified dates and shifts. The census numbers and the corresponding number of NAs required versus those who actually worked were documented, highlighting the shortfall in staffing levels across various shifts and dates.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days of 7/2, 7/4, 7/5, 7/7, 11/7, 12/12, 12/13, 12/14, 12/15 where minimal staffing ratio was not met, but PPD was met on all days. Residents of The Lutheran Home at Kane will be protected from future nurse aide staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings and 1:15 for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The scheduler or designee will review projected staffing levels and audit to ensure staffing levels were met with the Director of Nursing or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. The Lutheran Home will continue to aggressively advertise externally for the recruitment of nursing assistant applicants to enhance current staffing levels. The Lutheran Home at Kane is an approved site of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing nurse aide training classes quarterly. The Lutheran Home has 8 NA students who are ready to complete their skills testing and have yet to be able to complete the testing as their tests have been cancelled several times. The Lutheran Home has scheduled them at different sites and the tests are still being consistently cancelled. This plan of correction will be followed but call offs and no call no shows are unpredictable, and we continue to cover them to the best of our abilities. The Lutheran Home is currently offering call-in incentives to entice employees to pick up unscheduled shifts and has instituted a positive points program as an incentive. The Lutheran Home at Kane will utilize agency staffing as appropriate. Staffing will be considered when reviewing referrals. Results of the audits will be reviewed at Quality Assurance Performance Improvement meetings.