(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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day shift on three of 21 days reviewed, a minimum of one nurse aide per 12 residents on 11 of 21 evening shifts reviewed, and 7 of 21 night shifts reviewed.
Findings include:
A review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:
Day shift:
December 30, 2023, 3.33 NAs for a census of 54, required 4.5. January 9, 2024, 4.13 NAs for a census of 53, required 4.42. January 14, 2024, 4.27 NAs for a census of 53, required 4.42.
Evening shift:
December 28, 2023, 3.97 NAs for a census of 54, required 4.5. December 31, 2023, 3.2 NAs for a census of 54, required 4.5. January 2, 2024, 3.82 NAs for a census of 53, required 4.42. January 9, 2024, 4.27 NAs for a census of 53, required 4.42. January 11, 2024, 3.77 NAs for a census of 53, required 4.42. January 13, 2024, 4.36 NAs for a census of 53, required 4.42. January 15, 2024, 3.15 NAs for a census of 53, required 3.15. January 30, 2024, 3.82 NAs for a census of 54, required 4.5. February 2, 2024, 3.75 NAs for a census of 54, required 4.5. February 4, 2024, 4.22 NAs for a census of 54, required 4.5. February 5, 2024, 4.27 NAs for a census of 55, required 4.58.
Night shift:
December 28, 2023, 2.16 NAs for a census of 54, required 2.7. December 29, 2023, 2.67 NAs for a census of 54, required 2.7. December 30, 2023, 2.67 NAs for a census of 54, required 2.7. December 31, 2023, 2.67 NAs for a census of 54, required 2.7. February 3, 2024, 2.64 NAs for a census of 54, required 2.7. February 4, 2024, 2.37 NAs for a census of 54, required 2.7. February 5, 2024, 2.65 NAs for a census of 55, required 2.75.
The Nursing Home Administrator and Director of Nursing confirmed the above findings on February 6, 2024, at 1:52 PM.
| | Plan of Correction - To be completed: 03/21/2024
1. Facility cannot retroactively correct
2. Facility will continue to recruit and retain CNA staff through a variety of services.
3. NHA/Designee will educate the scheduler and IDT on the staffing Ratios.
4. DON or designee will conduct review of staffing deployment assignments daily to ensure the CNA staffing ratio is being met for a period of 4 weeks and a weekly review x 1 month. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.
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