Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on one day, as mandated by regulation. The Nursing Home Administrator confirmed these staffing shortfalls during an interview, and the documentation reviewed detailed the census and actual NA hours compared to the required hours for each shift where deficiencies occurred.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated the NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5 times weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.