Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations regarding minimum nurse aide (NA) staffing levels across all three shifts. A review of nursing staff care hours and interviews with staff revealed that, for multiple days within the reviewed periods, the number of NAs scheduled did not meet the required ratios based on the resident census. Specifically, during the day shift, the facility did not provide at least one NA per 10 residents for 11 out of 21 days reviewed. During the evening shift, the required ratio of one NA per 11 residents was not met for 19 out of 21 days, and during the night shift, the ratio of one NA per 15 residents was not met for 19 out of 21 days. The deficiency was identified through a detailed review of staffing schedules and resident census data for several weeks. On numerous specific dates, the number of NAs scheduled was consistently below the minimum required for the census present on each shift. These findings were confirmed and discussed with the Nursing Home Administrator and the Director of Nursing during the survey process. No information about individual residents or their medical conditions was provided in the report.
Plan Of Correction
The facility cannot retroactively correct past nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.