Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident 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 and one NA per 15 residents during the overnight shift for several days in December 2024. On December 19 and 28, the facility's census required 7.10 and 6.50 NAs respectively during the day shift, but only 6.47 and 5.63 NAs were provided. Similarly, on December 15, 19, 20, and 21, the overnight shifts required 4.47, 4.73, 4.80, and 4.73 NAs respectively, but the facility provided only 3.24, 4.38, 4.29, and 4.22 NAs. The deficiency was confirmed through a review of nursing schedules, staffing information, and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required staffing ratios on the specified days. No additional higher-level staff were available to compensate for these deficiencies, indicating a failure to ensure adequate staffing levels to meet regulatory requirements.
Plan Of Correction
The facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. The facility will continue to take measures to adequately provide staff to meet the required nurse aide to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum staffing ratios to Registered Nurse Supervisors, Human Resources, and Scheduling who are responsible to maintain adequate staffing and staffing ratios. The Director of Nursing or designee will re-educate Human Resources, Scheduler and Registered Nurse supervisors of protocols for calling in staff related to call offs. The Director of Nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed after a call off occurred. These audits will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.