Staffing Deficiencies in Nurse Aide 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 per residents during various shifts over a six-day period from March 25 to March 30, 2025. On five of these days, the day shift was understaffed, with the number of NAs falling short of the required ratio. Additionally, the evening shift was understaffed on one day, and the night shift was understaffed on four days. The facility's census data and nursing time schedules were reviewed, revealing discrepancies between the required and actual staffing levels. The facility census varied from 93 to 98 residents during the reviewed period, necessitating specific numbers of NAs per shift to comply with the regulation. However, the actual staffing levels consistently fell short, with the most significant deficiencies noted on the day and night shifts. Interviews with the Nursing Home Administrator confirmed the facility's failure to meet the staffing requirements, and there were no additional higher-level staff available to compensate for these deficiencies.
Plan Of Correction
1. Facility unable to correct nurse aide staffing hours for the cited 5 of 6 days on day shift, 1 of 6 days for evening shift, and 4 of 6 days for night shift. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit the direct care staffing five times per week to ensure regulatory compliance. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.