(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations: Based on review of nursing time schedules and staff interviews it was determined that the facility failed to provide a minimum of one nurse aide per twelve residents during the dayshift on two of 21 days (12/25/23 and 1/23/24) , failed to provide one nurse aide per twelve residents during the evening shift on nine of 21 days (12/25/23, 12/26/23, 12/27/23, 12/29/23, 1/1/24, 1/2/24, 1/3/24, 1/22/24 and 1/23/24) and failed to provide one nurse aide per 20 residents during the night shift on 13 of 21 days (12/27/23, 12/29/23, 12/30/23, 12/31/23, 1/1/24, 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/19/24, 1/23/24 and 1/25/24).
Findings include:
Review of facility census data indicated that on 12/24/23, the facility census was 39, which required 1.56 Licensed Practical Nurse's (LPN) on the daylight shift with 1.0 LPN's scheduled and the facility census was 40 on the evening shift which required 1.33 LPN's with 1,03 LPN's scheduled. The additional excess higher level staff were calculated to compensate but did not meet the requirements. During an interview on 1/24/24, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents on daylight and evening shifts and one nurse aide per 20 residents on the overnight shift.
| | Plan of Correction - To be completed: 03/05/2024
The facility will persist in taking measures to provide adequate staff to meet resident needs including the required nurse aide to resident ratios on day shift, evening shift, & night shift. The Director of Nursing/Designee will re-educate the scheduler, RN supervisors, and HR, on minimum staff ratios by March 5, 2024. The Director of Nursing/Designee will audit daily staffing schedules to ensure the minimum number of nurse aide to resident ratios are being met x 2 weeks followed by weekly x 4 weeks. Results will be monitored in QA/QI x 3 months.
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