Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios across multiple shifts, as evidenced by a review of weekly staffing records. On numerous occasions, the number of nurse aides scheduled for the day, evening, and night shifts did not meet the mandated ratios based on the facility's census. For example, on several dates, the day shift had fewer nurse aides than the required 1:10 ratio, the evening shift fell short of the 1:11 ratio, and the night shift did not meet the 1:15 ratio. These deficiencies were documented for a total of 45 out of 63 reviewed shifts. Specific staffing shortfalls were detailed, including instances where the number of nurse aides was below the required threshold for the number of residents present. The report lists exact numbers for each shift and census, showing consistent under-staffing. Additionally, it was noted that on these dates, there were no additional higher-level staff available to compensate for the lack of nurse aides. An interview with the Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the identified dates. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency.
Plan Of Correction
The facility cannot correct the CNA staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the CNA staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations. The facility cannot correct the LPN staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the LPN staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.