(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 ensure a minimum of one nurse aide (NA) per 10 residents on the day shift for seventeen of 21 days (11/17/24, 11/18/24, 11/19/24, 11/21/24, 11/22/24, 11/23/24, 12/09/24, 12/11/24, 12/12/24, 12/14/24, 12/15/24, 1/05/25, 1/06/25, 1/07/25, 1/09/25, 1/10/25 and 1/11/25); failed to ensure one NA per 11 residents on the evening shift for seventeen of 21 days (11/20/24, 11/22/24, 11/23/24, 12/09/24, through 12/15/24, and 1/05/25 through 1/11/25); and failed to ensure one NA per 15 residents on the overnight shift, for twelve of 21 days reviewed for staffing ratio (11/19/24, 11/20/24, 12/09/24, 12/10/24, 12/12/24, 1/05/25, 1/06/25, 1/07/25, 1/09/25, 1/10/25 and 1/11/25).
Findings include:
Review of facility nursing staffing documents for the time periods from 11/17/24, through 11/23/24, 12/09/24 through 12/15/24, and 1/05/25 through 1/11/25, revealed the following staffing shortages where the minimun required NA ratios were not met for the day shift:
11/17/24, facility census of 108 residents, 8.53 NAs worked and 10.80 were required.
11/18/24, facility census of 108 residents, 9.00 NAs worked and 10.80 were required.
11/19/24, facility census of 106 residents, 9.00 NAs worked and 10.60 were required.
11/20/24, facility census of 105 residents, 9.00 NAs worked and 10.50 were required.
11/21/24, facility census of 105 residents, 9.00 NAs worked and 10.50 were required.
11/22/24, facility census of 105 residents, 10.00 NAs worked and 10.50 were required.
11/23/24, facility census of 105 residents, 9.00 NAs worked and 10.50 were required.
12/09/24, facility census of 101 residents, 8.53 NAs worked and 10.10 were required.
12/11/24, facility census of 103 residents, 9.00 NAs worked and 10.30 were required.
12/12/24, facility census of 102 residents, 9.00 NAs worked and 10.20 were required.
12/14/24, facility census of 103 residents, 10.00 NAs worked and 10.30 were required.
12/15/24, facility census of 104 residents, 8.00 NAs worked and 10.40 were required.
1/05/25, facility census of 99 residents, 8.00 NAs worked and 9.90 were required.
1/06/25, facility census of 101 residents, 9.00 NAs worked and 10.10 were required.
1/07/25, facility census of 102 residents, 9.00 NAs worked and 10.10 were required.
1/09/25, facility census of 103 residents, 10.00 NAs worked and 10.30 were required.
1/11/25, facility census of 105 residents, 7.37 NAs worked and 10.50 were required.
Review of facility nursing staffing documents for the time periods from 11/17/24 through 11/23/24, 12/09/24 through 12/15/24, and 1/05/25 through 1/11/25, revealed the following staffing shortages where the minimun required NA ratios were not met for the evening shift:
11/20/24, facility census of 105 residents, 7.00 NAs worked and 9.55 were required.
11/21/24, facility census of 105 residents, 9.47 NAs worked and 9.55 were required.
11/23/24, facility census of 105 residents, 8.53 NAs worked and 9.55 were required.
12/09/24, facility census of 101 residents, 6.00 NAs worked and 9.18 were required.
12/10/24, facility census of 103 residents, 8.53 NAs worked and 9.36 were required.
12/11/24, facility census of 103 residents, 9.20 NAs worked and 9.36 were required.
12/12/24, facility census of 102 residents, 8.53 NAs worked and 9.27 were required.
12/13/24, facility census of 103 residents, 8.00 NAs worked and 9.36 were required.
12/14/24, facility census of 103 residents, 8.00 NAs worked and 9.36 were required.
12/15/24, facility census of 104 residents, 8.80 NAs worked and 9.45 were required.
1/05/25, facility census of 99 residents, 7.00 NAs worked and 6.67 were required.
1/06/25, facility census of 101 residents, 8.27 NAs worked and 9.18 were required.
1/07/25, facility census of 102 residents, 6.00 NAs worked and 9.27 were required.
1/08/25, facility census of 102 residents, 8.53 NAs worked and 9.27 were required.
1/09/25, facility census of 103 residents, 7.47 NAs worked and 9.36 were required.
1/10/25, facility census of 103 residents, 8.00 NAs worked and 9.36 were required.
1/11/25, facility census of 105 residents, 6.07 NAs worked and 9.55 were required.
Review of facility nursing staffing documents for the time periods from 11/17/24 through 11/23/24, 12/09/24 through 12/15/24, and 1/05/25 through 1/11/25, revealed the following staffing shortages where the minimun required NA ratios were not met for the overnight shift:
11/19/24, facility census of 108 residents, 8.53 NAs worked and 9.64 were required.
11/20/24, facility census of 105 residents, 6.00 NAs worked and 7.00 were required.
11/23/24, facility census of 105 residents, 5.00 NAs worked and 7.00 were required.
12/09/24, facility census of 101 residents, 4.00 NAs worked and 6.73 were required.
12/10/24, facility census of 103 residents, 6.00 NAs worked and 6.87 were required.
12/12/24, facility census of 102 residents, 5.00 NAs worked and 6.86 were required.
1/05/25, facility census of 99 residents, 5.00 NAs worked and 6.60 were required.
1/06/25, facility census of 101 residents, 4.00 NAs worked and 6.73 were required.
1/07/25, facility census of 102 residents, 5.00 NAs worked and 6.80 were required.
1/09/25, facility census of 103 residents, 5.00 NAs worked and 6.87 were required.
1/10/25, facility census of 103 residents, 6.40 NAs worked and 6.87 were required.
1/11/25, facility census of 105 residents, 6.00 NAs worked and 7.00 were required.
During an interview on 1/15/25, at 10:10 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 03/02/2025
Facility will continue to discourage unexpected call offs which may result in Nursing Aide ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources.
Educations completed on staffing ratios for Nurses aides, call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing(DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses.
Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours
Nursing Aid Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews NA ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty.
Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to me more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program.
Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement(QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation.
Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet NA needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly there after.
QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
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