Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility was found to be non-compliant with the Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to maintain the required nurse aide-to-resident ratios during various shifts over a 21-day review period. On two occasions during the day shift, the facility did not meet the minimum requirement of one nurse aide per 10 residents. Similarly, the evening shift fell short of the required one nurse aide per 11 residents on one occasion. The night shift was particularly problematic, with four instances where the facility did not meet the required one nurse aide per 15 residents. The specific dates and staffing levels were documented, showing that on April 20 and April 27, the day shift was understaffed, while the evening shift on April 20 and the night shifts on April 23, 27, 28, and 29 were also below the required staffing levels. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these deficiencies, acknowledging that the facility did not meet the regulatory nurse aide-to-resident ratios as required by the state regulations.
Plan Of Correction
The facility cannot retroactively correct past Nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.