Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratios on several occasions during the review period. Specifically, for the day shift, the facility did not provide the mandated one NA per 10 residents on four days, as staffing records showed fewer NAs scheduled than required based on the census. For the evening shift, the facility did not meet the one NA per 11 residents requirement on two days, again scheduling fewer NAs than needed. These findings were confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfalls on the identified dates and shifts. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Plan Of Correction
The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required nurse aide to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling, who are responsible for maintaining adequate nurse aide staffing and nurse aide staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors on protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 times per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets nurse aide ratios. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met, using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, posting needs, posting needs with agencies, offering bonuses, and mandating staff when needed. The facility has ads posted on Indeed and recently increased our shift differential for nurse aides on second and third shifts, resulting in an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.