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 15 residents on the overnight shift for one of 21 days reviewed (1/13/25).
Findings include:
Review of facility nursing staffing documents for the time period from 1/10/25 through 1/30/25, revealed the following NA staffing shortage for the overnight shift where the NA ratio was not met:
1/13/25census of 74 residents4.53 NAs worked and 4.93 were required
During an interview on 2/03/25, at 1:49 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratio for the above date and shift.
| | Plan of Correction - To be completed: 02/17/2025
The facility will provide staff to ensure the needs of residents are met. The facility will produce daily schedule to meet the required nurse aide to resident ratios on all shifts. The facility will also utilize licensed staff when needed to fulfil the aide need.
The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate nurse aide staffing and nurse aide staffing ratios. Director of Nursing or designee will educate HR/ Scheduler and RN supervisors of protocols for replacing staff related to call offs including mandating staff when replacement staff are unable to be found. The facility shall also utilize licensed staff to help fill the CNA openings when able.
The Director of Nursing or designee will meet 5x per week x4 weeks to audit daily deployment sheet for accuracy to ensure daily schedule meets nurse aide ratio. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met using the Department of Health staffing grid x4 weeks
The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, asking licensed staff to stay, posting need, posting need with agencies, offering bonus, mandating when needed. The facility has ads posted on indeed and recently increase our shift differential for nurse aides on second and third shift with an increase in applications the last six weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved
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