Observations:
Based on review of the facility staffing documents for 5/6/24, through 5/15/24, and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 12 residents for day shift for one of ten days reviewed (5/12/24).
Findings include:
Review of facility staffing ratio information from 5/6/24, through 5/15/24, revealed the following NA staffing shortage for the day shift where the NA ratios were not met:
5/12/24census of 85 residents6.50 NA worked and 7.08 were required
During an interview on 5/20/24, at 3:01 p.m. the Nursing Home Administrator confirmed the NA ratio was not met for the above date and shift.
| | Plan of Correction - To be completed: 07/08/2024
The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. The facility will continue to take measures to adequately provide staff to meet the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff.
The Director of Nursing or designee will continue to educate staffing ratios to RN Supervisors, HR, and scheduling who are responsible to maintain adequate staffing and staffing ratios. The Leading Age PA Ratio and PPD Planning Tool is being used to assist staff. The scheduler is utilizing the new DOH spreadsheet. All admissions will continue to be reviewed for scheduled PPD and Ratios prior to acceptance. The scheduler looks at trends of call offs and will attempt to schedule anticipating call offs. As call offs occur we will message all RN, LPN, and CNA staff offering bonus to come in and finish the shift.
The Director of Nursing or designee will audit the daily schedules to ensure that the staff to resident ratios have been scheduled.
These audits will be conducted weekly until cleared by Quality Assurance and Process Improvement meeting.
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