Failure to Maintain Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) to resident staffing ratios on three of twenty-one reviewed shifts, as identified through a review of weekly staffing records and staff interviews. State regulations effective July 1, 2024, require a minimum of 1 NA per 10 residents on the day shift, 1 NA per 11 residents on the evening shift, and 1 NA per 15 residents on the night shift. For a census of 28 residents, the facility was required to staff 2.8 NAs on the day shift and 2.55 NAs on the evening shift. On one evening shift, the facility staffed 2.13 NAs instead of the required 2.55, and on a separate day shift, the facility staffed 2.53 NAs instead of the required 2.8. On another evening shift, the facility again staffed 2.13 NAs instead of 2.55. The records also showed that there were no additional higher-level staff available on those dates to compensate for the NA shortfalls. In an interview, the Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels compared to regulatory requirements for the facility’s census.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to CNAS for 3 shifts. 2.A facility wide audit was completed to ensure ratios were met. CNA sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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