Observations:
Based on review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 20 residents for the overnight shift for two of 21 days reviewed (10/03/23 and 2/18/24).
Findings include:
Review of facility staffing ratio information from 10/1/23 through 10/7/23, and 2/18/24 through 3/10/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
10/03/23 census of 57 residents 2.00 NAs worked and 2.85 were required 2/18/24census of 61 residents3.00 NAs worked and 3.05 were required
Review of an email correspondence interview dated 3/27/24, at 11:56 a.m. revealed the Nursing Home Administrator confirmed the NA ratios were not met for the above dates and shift.
| | Plan of Correction - To be completed: 05/08/2024
The facility will ensure that it meets the minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels. The Nursing Home Administrator has reviewed and educated the Director of Nursing, and the Unit Manager and the schedular staff member on ensuring that the facility meets the minimum nurse aide to resident ratio. We will institute the following system changes to ensure we meet the staffing ratios:
We will have a Staffing Schedular Computer Program that will predict our staffing needs. This program will alert staff of openings to meet staffing needs. Management staff or designee will review the potential admission numbers to ensure appropriate census levels are maintained. We will continue to offer additional time to our staff members which may include agency and continue to offer extra shift bonuses for current employees, ensure all our vacant positions are currently in recruitment and advertised appropriately.
The Director of Nursing or designee will audit to ensure that facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Monitoring will be conducted once a week for one month, then two times a week for one month, then monthly for 2 months.
Monitoring will be reviewed at the quarterly QAPI Meeting and additional recommendations will be followed as deemed appropriate.
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