Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratio during the overnight shift for 18 out of 21 days reviewed. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply with this requirement on multiple occasions. The review of nursing staffing documents revealed that the number of NAs working was consistently below the required number based on the facility's census. For instance, on several dates, the facility had a census of 89 to 90 residents, but the number of NAs working ranged from 4.75 to 5.75, whereas the required number was between 5.80 and 6.00. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the staffing requirements on the specified dates. This deficiency was identified through a review of staffing documents and an interview with the administrator, highlighting a consistent shortfall in staffing levels during the overnight shift over the reviewed periods.
Plan Of Correction
Facility Staffing Coordinator was reeducated on current CNA staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census. Nursing Supervisors to be in-serviced on staffing guidelines by 1/8/2025. For the shifts on the dates indicated, all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s), or employees. Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor, or Staffing Coordinator. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personnel that is needed. Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee.