Failure to Maintain Required NA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nursing assistants (NAs) on multiple occasions, as evidenced by a review of nursing staff schedules and interviews with staff. Specifically, the facility did not meet the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift on four out of seven days reviewed. On April 1 and April 2, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day and evening shifts, and the day and overnight shifts, respectively. On April 4, 2025, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening shift. On April 5, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day shift.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.