Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulation for several shifts over multiple days. Specifically, on three days, the day shift did not have the minimum required number of NAs per resident, with actual staffing falling short of the calculated requirement based on the resident census. On two days, the evening shift also did not meet the required NA-to-resident ratio, and on three days, the overnight shift was similarly understaffed. These deficiencies were identified through a review of facility nursing staffing documents covering several time periods. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the specified days and shifts. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The findings are based solely on staffing records and administrative confirmation.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility should utilize the following process: 1. In an attempt to achieve appropriate staffing ratios, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. Additionally, the Scheduler will be re-educated on the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. In the event that the Supervisor is unable to fully cover the hours of a staff call-off and the loss of staff might impact the facility's compliance with the regulatory requirement, the RN Supervisor will notify the Director of Nursing and Assistant Director of Nursing so that all administrative clinical staff can be notified of the need so they can assist with coverage. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months then quarterly until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.