(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 nurse staffing documents, resident interview and staff interview, it was determined that the facility failed to provide the State required minimum of one Nurse Aide (NA) per ten residents on the daylight shifts for 11 out of 21 days (11/22/24, 11/23/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/4/24, 12/7/24, 12/8/24, and 12/9/24 ), one Nurse Aide (NA) per 11 residents on the evening shifts for 15 out of 21 shifts (11/22/24, 11/23/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/2/24, 12/3/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24 and 12/10/24) and failed to provide the State required minimum of one NA per 15 residents for the overnight shift on four out of 21 shifts (11/29/24, 12/3/24, 12/4/24, and 12/10/24).
Findings include:
A review of 3-week nurse staffing schedules (11/21/24-12/11/24) did not include the State required minimum of Nurse Aides (NA) on the daylight shifts for the following dates: (11/22/24, 11/23/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/4/24, 12/7/24, 12/8/24, and 12/9/24).
A review of 3-week nurse staffing schedules (11/21/24-12/11/24) did not include the State required minimum of Nurse Aides (NA) on the evening shifts for the following dates: (11/22/24, 11/23/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/2/24, 12/3/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24 and 12/10/24).
A review of 3-week nurse staffing schedules (11/21/24-12/11/24) did not include the State required minimum of Nurse Aides (NA) on the overnight shifts for the following dates: (11/29/24, 12/3/24, 12/4/24, and 12/10/24).
During an interview on 12/12/24, at 11:04 a.m. Resident R1 stated: "They are a little short on staff in the evenings."
During an interview on 12/12/24, at 11:23 a.m. Resident R2 stated: "They are short sometimes on staff here."
During an interview on 12/12/24, at 12:19 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide the State required minimum of one Nurse Aide (NA) per ten residents on the daylight shifts for 11 out of 21 days (11/22/24, 11/23/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/4/24, 12/7/24, 12/8/24, and 12/9/24 ), one Nurse Aide (NA) per 11 residents on the evening shifts for 15 out of 21 shifts (11/22/24, 11/23/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/2/24, 12/3/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24 and 12/10/24) and failed to provide the State required minimum of one NA per 15 residents for the overnight shift on four out of 21 shifts (11/29/24, 12/3/24, 12/4/24, and 12/10/24) as required.
| | Plan of Correction - To be completed: 01/13/2025
The facility cannot correct that nurse aide staffing ratios were not met on 11/22/24, 11/23/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24.
The facility will ensure that nurse aide staffing ratios are met every shift.
The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift.
Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.
The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met.
The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
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