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 number of nurse aides per residents during various shifts over a 21-day period. During the day shift, the facility was short of the required nurse aides on 12 out of 21 days. The evening shift experienced shortages on 14 out of 21 days, and the night shift was understaffed on 19 out of 21 days. The census data and nursing time schedules revealed that the facility consistently failed to meet the required nurse aide-to-resident ratios, with no additional higher-level staff available to compensate for these deficiencies. The Director of Nursing confirmed these staffing shortages during an interview, acknowledging the facility's failure to provide the mandated nurse aide coverage. The report details specific dates and census numbers, highlighting the discrepancies between the required and actual number of nurse aides present during each shift. This consistent understaffing indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility cannot correct that a minimum of one nurse aide (NA) per 10 residents during the day shift for 12 of 21 days (12/29 and 12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/10, 1/11, 1/12, 1/14, and 1/16/25), one NA per 11 residents during the evening shift for 14 of 21 days (12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/16, and 1/18 25) and one NA per 15 residents during the night shift for 19 of 21 days (12/29 and 12/30, 12/31/24, 1/1, 1/2/25, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/17, and 1/18/25). 2. The facility will ensure that nurse aide staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.