Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on several occasions across different shifts. During the day shift, the facility did not provide the required number of NAs for the resident census on two specific days, resulting in a shortfall of 0.7 and 0.43 NAs, respectively. Similarly, the evening shift experienced a deficiency in staffing on three days, with shortfalls ranging from 0.36 to 0.64 NAs. The night shift was also affected, with four days showing a lack of adequate staffing, with shortfalls ranging from 0.53 to 1.53 NAs. These deficiencies were confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to ensure that the facility had adequate resident to nurse aide (NA) ratio to meet the regulatory requirement effective July 1, 2024 of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. 3. Education regarding the nurse aide ratio of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of nurse aide ratio staffing will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.