Observations:
Based on review of facility staffing ratio information and staff interview, it was determined the facility failed to meet the Nurse Aide (NA) ratios for the overnight shift where the NA ratio of one NA per 20 residents was not met for the for one of 21 days reviewed (4/27/24).
Findings include:
Review of facility staffing ratio information from 4/11/24, through 5/01/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
4/27/24 census of 52 residents 2.52 NAs worked and 2.60 were required.
During a telephone interview on 5/14/24, at 10:40 a.m. the Nursing Home Administrator confirmed that the NA ratio was not met for the above identified date and shift.
| | Plan of Correction - To be completed: 06/28/2024
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Grove Manor agrees with the allegations and citations listed on the statement of deficiencies. Grove Manor maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Grove Manor's written credible allegation of compliance.
By submitting this plan of correction, Grove Manor does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Grove Manor reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
There were no negative care impacts to any resident as a result of the identified concern. The overall daily per patient day (PPD) staffing numbers remained over the state minimum. The facility cannot retroactively correct this finding.
The Director of Nursing will provide additional education to the nursing management team on the updated nurse aide to resident staffing ratios and hours per resident day. The staff schedule currently provides the scheduled coverage to meet the ratio requirements. When there is a scheduled or unscheduled absence, there is a shift pick-up bonus/financial incentive offered to staff to provide accurate staff to resident ratio. The facility will continue to advertise for, interview, and select its own staff. The Administrator and Director of Nursing continue to collaborate with temporary agency staff to provide support when necessary.
The Director of Nursing or Designee will audit staffing ratios daily, five times per week for four weeks, then re-evaluate the need to increase or decrease monitoring to verify that all measures are being taken to meet nurse aid staffing ratio requirements. The Nursing Home Administrator and/or Director of Nursing will utilize the most recent staffing grid provided by The Department of Health.
The Quality Assurance and Performance Improvement Committee will review audit findings monthly for further review and recommendations.
|
