Nurse Aide Staffing Shortages
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 during various shifts over a 21-day period. On the day shift, there was a shortage of nurse aides on two days, with 18.23 and 19.10 aides present instead of the required 20.40 for a census of 204 residents. On the evening shift, there was a shortage on one day, with 17.50 aides present instead of the required 18.55. The night shift experienced shortages on four days, with the number of aides present ranging from 11.90 to 13.30, all below the required numbers for the respective resident census. The Nursing Home Administrator confirmed these staffing deficiencies during an interview, acknowledging the failure to meet the minimum staffing requirements without compensating with higher-level staff.
Plan Of Correction
The Center continues to have retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, and split shifts. We call unscheduled staff and supplemental staffing agencies to provide additional staff when shortages are noted. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure CNA ratios are being met on day and night shifts. Audit results will be reviewed with the QAPI Committee meeting monthly to determine the need for further audits.