Nurse Aide Staffing Deficiency
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 an 18-day period. During the day shift, the facility was short of the required nurse aide staffing on eleven days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was consistently below the required ratio of one nurse aide per 10 residents. Similarly, during the evening shift, the facility failed to meet the required staffing levels on eleven days, with the census ranging from 84 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 11 residents. Additionally, the facility did not meet the required staffing levels during the night shift on three days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 15 residents. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging the failure to provide the minimum required nurse aide staffing levels across the different shifts. There was no indication of additional higher-level staff being available to compensate for these deficiencies.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide to resident ratios on 12/1/24 through 12/18/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator or Designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. The facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.