Failure to Meet Minimum Nurse Aide and LPN Staffing Requirements
Penalty
Summary
The facility administrative staff failed to meet required minimum staffing levels for nurse aides (NAs) and licensed practical nurses (LPNs) over a 21-day review period. Specifically, there were multiple days when the number of NAs on duty did not meet the mandated ratios for day, evening, and overnight shifts. For the day shift, the facility did not provide at least one NA per 10 residents on five days. On the evening shift, the required one NA per 11 residents was not met on two days, and for the overnight shift, the one NA per 15 residents requirement was not met on ten days. These shortages were confirmed through a review of census data, nursing time schedules, and staff interviews, with no evidence of additional higher-level staff compensating for the deficiencies. Additionally, the facility did not meet the minimum LPN staffing requirements. On seven days, the day shift did not have at least one LPN per 25 residents, and on two days, the evening shift did not have one LPN per 35 residents. These findings were also confirmed by census data, time schedules, and staff interviews. The Nursing Home Administrator acknowledged the staffing shortages and confirmed that the required staffing levels were not maintained, with no compensatory measures in place.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open CNA positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure CNA ratios are being met. Scheduler will continue to monitor CNA ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed. NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open LPN positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure LPN ratios are being met. Scheduler will continue to monitor LPN ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.