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 three days, and one NA per 15 residents during the night shift on two days. Staffing records showed that the actual NA hours provided were below the required hours for the census on these dates. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required NA staffing levels on the identified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shift's staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility is utilizing agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, the scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. Daily recruiting calls occur to update the status of new applicants and interviews. The 3-week DOH Staffing Calculator Tool will be updated daily to monitor hours. The audits will be taken to QAPI for review.