Failure to Meet Minimum Nurse Aide Staffing Ratios Across All Shifts
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios for all three shifts over a 21-day review period. Specifically, during the day shift, the number of nurse aides consistently fell below the mandated ratio of one nurse aide per ten residents on all 21 days reviewed. The evening shift also did not meet the required ratio of one nurse aide per eleven residents on 16 out of 21 days. Similarly, the overnight shift failed to provide at least one nurse aide per fifteen residents on 20 out of 21 days. These findings were based on a review of staffing records, which detailed the census and number of nurse aides present for each shift and day within the review period. An interview with the Administrator confirmed the accuracy of the staffing data and the facility's failure to meet the minimum nurse aide requirements as outlined by regulation. The report does not mention any specific residents or their medical conditions, nor does it describe any direct patient outcomes related to the staffing deficiencies. The deficiency is solely based on the facility's inability to provide the required number of nurse aides per shift according to the resident census.
Plan Of Correction
P 5520 Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P5520 1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in attempt to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.