Failure to Meet Nurse Aide Staffing 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 provide the necessary number of NAs during the day shift on two occasions and during the night shift on five occasions over a 21-day review period. On November 24 and 29, 2024, the facility census required 7.50 NAs during the day shift, but only 7.20 and 7.02 NAs were provided, respectively. Additionally, on several nights, the facility did not meet the required NA-to-resident ratio, with staffing levels falling short of the required numbers. 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. There were no additional higher-level staff available to compensate for these deficiencies, indicating a failure to adhere to the staffing requirements set forth by the regulation.
Plan Of Correction
The nursing schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. The daily schedule will be reviewed during the daily stand-up meeting. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. The staffing tool audit will be completed daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that nursing ratios are met for the daylight, evening, and overnight shifts. The audit will be monitored by the Director of Nursing or Designee.