(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 eight of 20 days reviewed (7/13/24, 7/14/24, 7/20/24, 7/21/24, 7/24/24, 7/27/24, 7/28/24, and 7/29/24); and the NA ratio of one NA per 11 residents on the evening shift for three of 20 days reviewed (7/20/24, 7/26/24 and 7/29/24); and the NA ratio of one NA per 15 residents on the overnight shift for three of 20 days reviewed (7/24/24, 7/25/24, and 7/27/24).
Findings include:
Review of facility nursing staffing ratio information for the time period from 7/13/24, through 7/3024, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
7/13/24census of 114 residents10.33 NAs worked and 11.40 were required
7/14/24census of 114 residents10.80 NAs worked and 11.40 were required
7/20/24census of 111 residents8.73 NAs worked and 11.10 were required
7/21/24census of 111 residents9.33 NAs worked and 11.10 were required
7/24/24census of 112 residents10.53 NAs worked and 11.20 were required
7/27/24census of 117 residents9.20 NAs worked and 11.70 were required
7/28/24census of 116 residents8.26 NAs worked and 11.60 were required
7/29/24census of 118 residents11.00 NAs worked and 11.80 were required
Review of facility nursing staffing ratio information for the time period from 7/13/24, through 7/30/24, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
7/20/24census of 111 residents10.06 NAs worked and 10.90 were required
7/26/24census of 115 residents10.13 NAs worked and 10.45 were required
7/29/24census of 118 residents10.66 NAs worked and 10.73 were required
Review of facility nursing staffing ratio information for the time period from 7/13/24, through 7/30/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
7/24/24census of 112 residents7.33 NAs worked and 7.47 were required
7/25/24census of 115 residents7.53 NAs worked and 7.67 were required
7/27/24census of 117 residents6.40 NAs worked and 7.80 were required
During a telephone interview on 8/2/24, at 1:54 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratio for the above days and shifts.
| | Plan of Correction - To be completed: 10/18/2024
This plan does not constitute an admission that any of the citations are legal or factually correct. This plan of correction is not meant to establish a standard of care, contract, obligation or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding, please accept this plan of correction as Edinboro Manor credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident.
Residents of Edinboro Manor will be protected from future staff ratios below the 1:10 nurse aide for days and 1:11 nurse aides evening and 1:15 nurse aide for nights by a proactive preview of daily staff coverage by the DON/Designee. The nurse scheduler/designee will review projected staffing levels for 3 weeks to ensure that any forseeable staffing level below nurse aide ratios are adequately covered. Edinboro Manor will continue to aggressively advertise externally for recruitment of CNA applicants to enhance current staffing levels. Edinboro Manor will also review potential admissions and may reconsider admissions if the facility is unable to meet minimum staffing levels. Edinboro Manor is an approved provider of the Pennsylvania Nurse Aide Training and competency evaluation program and has ongoing class training throughout the year. Edinboro Manor will be starting a class of CNA's on 9/3/2024. These students will be finished with their classroom and clinicals on September 26 with eligibility to sit for the CNA written and skilled exams. Another new class with six students will start in October. Edinboro Manor will also offer bonus payment and extra incentives to current staff to cover extra shifts. Staffing ratios will be reviewed by DON/Designee 3x a week for a month, then weekly x3 weeks then monthly for two months. Results will be reported on a monthly basis during monthly QAPI committee meetings and at Quarterly Quality Assurance/QAPI Meetings. 3-5 times q weekly we will have a staffing meeting to discuss ratios, PPD and staffing (open positions) to ensure we can sustain compliance in the future.
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