Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides across multiple shifts over a period of 12 out of 21 days. Specifically, the facility did not provide the mandated minimum of one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. This deficiency was identified through a review of nursing schedules and census information, which revealed consistent shortfalls in the number of nurse aide hours provided compared to what was required. The shortfalls in staffing were documented on specific dates, with discrepancies ranging from minor to significant. For instance, on several occasions, the facility provided fewer hours of nurse aide care than required, such as providing only 67.50 hours when 73.00 were needed on a night shift. The Nursing Home Administrator confirmed these staffing deficiencies during a follow-up communication, acknowledging the failure to meet the regulatory staffing requirements on the specified days.
Plan Of Correction
The facility will implement a corrective staffing plan led by the Staffing Coordinator and overseen by the Director of Nursing and Administrator. The Staffing Coordinator will use a facility software to verify projected ratios tracking tool to calculate required hours per shift daily based on resident census and will ensure adequate staffing coverage is planned in advance. A float pool and an on-call list of PRN staff will be developed to cover unexpected absences or shortfalls. Additionally, the facility will continue the recruitment effort to increase the availability of certified nurse aides. Starting June 9, daily staffing compliance reports will be submitted to the Administrator and reviewed in QAPI meeting. In-service training will be conducted for administrative staff on regulatory staffing requirements and the importance of maintaining minimum staffing ratios. To ensure sustained compliance, the Administrator or designee will conduct weekly audits of the staffing schedules to: - Compare projected vs. actual staffing per shift - Verify adherence to required ratios - Ensure appropriate documentation and use of PRN/on-call staff when needed Audit results will be discussed in weekly QAPI meetings beginning June 9, 2025. After the initial 30-day audit period, the facility will continue with monthly audits through the remainder of the calendar year to ensure ongoing compliance.