(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 staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift for two of five days (7/20/24 and 7/21/24), one NA per 11 residents on the second shift for three of five days (7/19/24, 7/20/24 and 7/21/24) and one NA per 15 residents on the night shift on two of five days (7/18/24 and 7/20/24) as required.
Findings include:
A review of facility staffing documents provided by the facility revealed the facility failed to provide NA on the following shifts as required:
Daylight shift:
DateCensusActual hours Hours required
7/20/248748.0054.38
7/21/248647.2753.75
Evening shift:CensusActual hoursHours required
7/19/248845.5855.00
7/20/248740.6654.38
7/21/248647.3353.75
Night shift:CensusActual hoursHours required
7/18/248731.4832.63
7/20/248724.2232.63
During an interview on 7/25/24 at 8:03 a.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.
| | Plan of Correction - To be completed: 08/07/2024
P 5510 - No residents were affected during the days identified in the 2567. The Administrator, Director of Nursing and Staffing Coordinator were re-educated regarding minimum staffing ratios for Nurse Aides by the Corporate Clinical Director. The facility is utilizing staffing agencies for additional staffing options. Monetary shift bonuses are being offered to induce coverage. The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites. The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule. The facility is utilizing progressive discipline for those who breach the attendance policy. The Director of Nursing or designee will monitor the staffing ratios for nurse aides 5 times a week for 4 weeks. Results of audits will be reviewed at the facilities quality assurance performance improvement meeting. The facility Administrator will ensure compliance.
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