(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 staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide (NA) per 12 residents on day shift for two of seven days (March 8 and 10, 2024) and one nurse aide per 12 residents on evening shift for four of seven days reviewed (March 5, 6, 7, and 8, 2024).
Findings include:
Review of facility-provided staffing ratio information for March 5, 2024, on evening shift, revealed a census of 142 residents. Further review revealed an NA ratio of 10.97; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.
Review of facility-provided staffing ratio information for March 6, 2024, on evening shift, revealed a census of 142 residents. Further review revealed an NA ratio of 10.22; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.
Review of facility-provided staffing ratio information for March 7, 2024, on evening shift, revealed a census of 142 residents. Further review revealed an NA ratio of 10.84; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.
Review of facility-provided staffing ratio information for March 8, 2024, on day and evening shifts, revealed a census of 142 residents. Further review revealed an NA ratio of 10.38 on day shift and 7.66 on evening shift; therefore, the facility did not meet the required minimum NA ratio for the facility census on those shifts.
Review of facility-provided staffing ratio information for March 10, 2024, on day shift, revealed a census of 140 residents. Further review revealed an NA ratio of 8.66; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.
During an interview with the Nursing Home Administrator on March 25, 2024, at 10:45 AM, he confirmed that the aforementioned dates did not meet the required staffing ratios.
| | Plan of Correction - To be completed: 04/24/2024
P5510
1. CNA ratios for 3/5/2024, 3/6/2024, 3/7/2024, 3/8/2024, and 3/10/2024 cannot be corrected as this is a past event.
2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler and DON/designee.
3. The facility has developed internal incentive to retain and attract new staff. Agency contracts are in place in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed.
4. In addition to previous corrective actions, the facility has conducted a re-class of agency wages to better attract staff. The facility is in approval phase of Baylor program to be offered to staff. HR is marketing/recruiting at the Gratz auction weekly. The facility has incorporated sign -on bonuses in efforts to retain and attract new staff. Agency contracts are in place in an effort to reach daily shift ratios. HR will also be attending job fairs as available. The scheduler will look ahead a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed. The facility will monitor census each shift and make all attempts to adjust CNA staffing to ensure ratio requirements are met. Results to QAPI.
5. Date of Correction: 4/24/24
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