Observations:
Based on review of facility staffing ratio information and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 12 residents for the evening shift for one of seven days reviewed (5/29/24).
Findings include:
Review of facility staffing ratio information for the time period from 5/29/24 through 6/06/24, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:
5/29/24 census of 105 residents 8.35 NAs worked and 8.75 were required.
During a telephone interview on 6/6/24, at 12:16 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratio for the above day and shift.
| | Plan of Correction - To be completed: 08/01/2024
1. Nurse aide sponsored advertisements for open positions posted on several recruitment websites in an effort to recruit new nurse aides to help fill open positions on evening and night shifts. There will be a summer recruitment event held in August to attract new applicants with open interviews. There will be increased advertisement for the event including giveaways and door prizes to attract candidates.
2. CNA class graduated 6/25/2024 with three students and another class is scheduled to start on 8/12/2024 with four CNA student applicants in the class so far. Starting 6/9/2024 a new critical premium pay policy was implemented for all CNA, LPN, and RN positions to help fill open shifts.
3. Education provided Scheduler and Nursing Supervisors on staffing ratios.
4. If staff is not available to work a scheduled shift that causes the shift to be below the required staffing ratios, all attempts will be made to cover the shift with nurse aides, LPNS and RNS.
5. Administrator or designee will audit the nurse aide staffing ratios for all shifts to ensure the staffing ratios meet the regulations weekly for 4 weeks, monthly for 3 weeks and quarterly thereafter.
6. Audits will be presented at the Quarterly Quality Assurance Meeting
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