Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide to resident staffing ratios on 14 out of 63 reviewed shifts. Staffing records showed that on multiple dates, the number of nurse aides scheduled for day, evening, and night shifts did not meet the regulatory requirements based on the facility's census. For example, on several night shifts, the number of nurse aides was below the required ratio for the number of residents present, and similar shortfalls were noted on day and evening shifts. No additional higher-level staff were available to compensate for these deficiencies on the affected dates. This deficiency was confirmed through a review of weekly staffing records and an interview with the Director of Nursing, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. We are actively recruiting Nurse Aides and offering sign-on bonuses for new employees and referral bonuses to current employees. The facility is advertising job postings on multiple recruiting platforms. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.