(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.
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Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on day shift for 13 of 21 days reviewed (7/6/24, 7/7/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/16/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/25/24, and 7/26/24); and the NA ratio of one NA per 11 residents on the evening shift for 11 of 21 days reviewed (7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/19/24, 7/20/24, and 7/24/24); and the NA ratio of one NA per 15 residents on the overnight shift for 19 of 21 days reviewed (7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17,24, 7/18/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24, 7/25/24, and 7/26/24).
Findings include:
Review of facility nursing staffing ratio information for the time period from 7/6/24, through 7/26/24, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
7/6/24 census of 39 residents3.73 NAs worked and 3.90 were required
7/7/24 census of 39 residents3.87 NAs worked and 3.90 were required
7/11/24 census of 41 residents3.80 NAs worked and 4.10 were required
7/12/24 census of 38 residents3.23 NAs worked and 3.80 were required
7/13/24 census of 40 residents3.50 NAs worked and 4.00 were required
7/14/24 census of 40 residents3.83 NAs worked and 4.00 were required
7/16/24 census of 39 residents3.17 NAs worked and 3.90 were required
7/18/24 census of 40 residents3.73 NAs worked and 4.00 were required
7/19/24 census of 40 residents3.33 NAs worked and 4.00 were required
7/20/24census of 40 residents3.27 NAs worked and 4.00 were required
7/21/24census of 40 residents3.20 NAs worked and 4.00 were required
7/25/24census of 41 residents3.70 NAs worked and 4.10 were required
7/26/24census of 42 residents3.77 NAs worked and 4.20 were required
Review of facility nursing staffing ratio information for the time period from 7/6/24, through 7/26/24, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:
7/8/24 census of 40 residents3.20 NAs worked and 3.64 were required
7/9/24 census of 41 residents3.20 NAs worked and 3.73 were required
7/10/24 census of 40 residents3.23 NAs worked and 3.64 were required
7/11/24 census of 41 residents3.20 NAs worked and 3.73 were required
7/12/24 census of 38 residents3.17 NAs worked and 3.45 were required
7/13/24 census of 40 residents2.87 NAs worked and 3.64 were required
7/14/24 census of 40 residents3.23 NAs worked and 4.64 were required
7/15/24 census of 39 residents3.20 NAs worked and 3.55 were required
7/19/24 census of 40 residents3.23 NAs worked and 3.64 were required
7/20/24census of 40 residents3.20 NAs worked and 3.64 were required
7/24/24census of 41 residents3.23 NAs worked and 3.73 were required
Review of facility nursing staffing ratio information for the time period from 7/6/24, through 7/26/24, revealed the following NA staffing shortage for the overnight shift where the NA ratios were not met:
7/6/24 census of 39 residents2.27 NAs worked and 2.60 were required
7/7/24 census of 39 residents2.20 NAs worked and 2.60 were required
7/8/24 census of 40 residents2.20 NAs worked and 2.67 were required
7/9/24 census of 41 residents2.40 NAs worked and 2.73 were required
7/10/24 census of 40 residents2.20 NAs worked and 2.67 were required
7/11/24 census of 41 residents2.60 NAs worked and 2.73 were required
7/12/24 census of 38 residents2.23 NAs worked and 2.53 were required
7/13/24 census of 40 residents2.50 NAs worked and 2.67 were required
7/15/24 census of 39 residents2.27 NAs worked and 2.60 were required
7/16/24 census of 39 residents2.20 NAs worked and 2.60 were required
7/17/24 census of 40 residents2.20 NAs worked and 2.67 were required
7/18/24 census of 40 residents1.87 NAs worked and 2.67 were required
7/20/24census of 40 residents2.57 NAs worked and 2.67 were required
7/21/24census of 40 residents2.23 NAs worked and 2.67 were required
7/22/24census of 40 residents2.50 NAs worked and 2.67 were required
7/23/24census of 41 residents2.20 NAs worked and 2.73 were required
7/24/24census of 41 residents2.17 NAs worked and 2.73 were required
7/25/24census of 41 residents2.17 NAs worked and 2.73 were required
7/26/24census of 42 residents2.23 NAs worked and 2.80 were required
During a telephone interview on 8/5/24, at 11:25 a.m. the Director of Nursing confirmed that the facility did not meet the minimum NA ratio for the above days and shifts.
| | Plan of Correction - To be completed: 09/20/2024
Highland View Healthcare will strive to more than adequately provide staff to ensure the needs of our residents are met. Further, the facility will continue to take every measure to provide staff to meet the nurse aide to resident ratios. Our efforts include continuing an active and strong retention committee, enhanced advertising efforts, utilization of agency staff, increase the ad exposure for our new pay rates and offering of sign-on bonuses.
The Director of Nursing or designee will continue to provide education on minimum staffing ratios to Registered Nurse Supervisors, Human Resources and scheduling as those responsible to assist in maintaining staffing ratios.
The team of the Director of Nursing, Assistant Director of Nursing and Administrator will monitor and audit schedules daily, with the goal of meeting the minimum number of staff to resident ratios.
In the event of a call-off, Highland View will initiate its procedure of contacting part time and per diem employees, offer overtime and shift pick-up bonuses to all applicable nursing personnel as well as contacting staffing agencies regarding the open shift(s).
The Nursing Home Administrator or designee will consider admission intake based on ratios and minimum Per Resident Day requirements.
Audits will continue to be conducted daily to monitor resident to staff ratios with results reported to the Quality
Assurance and Improvement Committee monthly.
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