(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.
|
Observations:
Based on review of the facility staffing documents for 7/03/24 through 7/09/24, and 7/28/24 through 8/10/24 and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents for the day shift for six of 21 days reviewed (7/06/24, 7/07/24, 8/04/24, 8/05/24, 8/07/24 and 8/10/24); failed to ensure a minimum of one NA per 11 residents for the evening shifts for two of 21 days reviewed 7/29/24, and 8/07/24); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for seven of 21 days reviewed (7/05/24, 7/07/24, 7/08/24, 8/04/24, 8/06/24, 8/07/24,and 8/08/24).
Findings include:
Review of facility staffing ratio information from 7/03/24 through 7/09/24, and 7/28/24 through 8/10/24, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
7/06/24 census of 43 residents 3.54 NA worked and 4.30 were required
7/07/24census of 43 residents3.02 NA worked and 4.30 were required
8/04/24census of 38 residents2.86 NA worked and 3.80 were required
8/05/24census of 40 residents3.00 NA worked and 4.00 were required
8/07/24census of 40 residents3.87 NA worked and 4.00 were required
8/10/24census of 40 residents3.93 NA worked and 4.00 were required
Review of facility staffing ratio information from 7/03/24 through 7/09/24, and 7/28/24 through 8/10/24, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
7/29/24 census of 39 residents 2.91 NA worked and 3.55 were required
8/07/24census of 40 residents3.07 NA worked and 3.64 were required
Review of facility staffing ratio information from 7/03/24 through 7/09/24, and 7/28/24 through 8/10/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
7/05/24 census of 44 residents 2.07 NA worked and 2.93 were required
7/07/24census of 44 residents2.01 NA worked and 2.93 were required
7/08/24census of 43 residents1.08 NA worked and 2.87 were required
8/04/24census of 38 residents2.32 NA worked and 2.53 were required
8/06/24census of 38 residents2.05 NA worked and 2.53 were required
8/07/24 census of 40 residents 2.15 NA worked and 2.67 were required
8/08/24census of 41 residents2.12 NA worked and 2.73 were required
During an interview on 8/14/24 at 3:11 p.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above days and shifts.
| | Plan of Correction - To be completed: 09/04/2024
No resident was found to be affected by the deficient practice of this new regulation.
The facility will make its best effort to maintain the one nurse aide to every ten residents for the day, 1 aide to every 11 residents on afternoon, and 1 aide to every 15 on night shift.
The administrator or designees will have a staffing meeting each morning to ensure the proper staff to resident ratios meet shift requirements.
The census is reviewed five days a week and will be maintained at 50 until open positions are filled with facility or agency staff.
Administrator or his designee will continue to recruit potential employees by placing ads on indeed and other recruiting mediums, networking within the community through Facebook and other social media.
Offering sign-on bonuses to potential employees.
Offering pick-up bonuses to staff that already work for the facility.
Sending hospitality aides to Certified Nursing Assistant training to get their certificate to provide direct care.
Offer a referral bonus to employees that encourage candidates to apply.
The facility will utilize LPN's as certified nursing aides when available.
The facility will increase recruiting efforts.
The facility will use the On-Shift program to make the schedule accessible to staff to see open shifts and pick them up.
The Administrator and his designee will monitor staffing 5 days a week for 4 weeks, reviewing the schedule for openings and placing staff where needed.
Staffing agencies will be used to staff the building on occurrence where the facility cannot staff with its employees.
The administrator and his designees will review the staffing concerns in Quarterly QAPI meetings.
The administrator and designees will review retention efforts, and root cause any issues that present themselves to ensure proper staffing ratios are maintained.
|
|
