(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.
|
Observations:
Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interview, it was determined that the facility failed to ensure a minimum of one NA per 15 residents on the overnight shift for four of seven days reviewed for May 13 through May 19, 2025.
Findings include:
Review of facility census data indicated that on May 15, 2025, the facility census was 87, which required 5.80 NA's during the night shift. Review of the nursing time schedules revealed 5.73 NA's provided care on the night shift on May 15, 2025. Review of facility census data indicated that on May 17, 2025, the facility census was 83, which required 5.53 NA's during the night shift. Review of the nursing time schedules revealed 5.28 NA's provided care on the night shift on May 17, 2025. Review of facility census data indicated that on May 18, 2025, the facility census was 85, which required 5.60 NA's during the night shift. Review of the nursing time schedules revealed 5.22 NA's provided care on the night shift on May 18, 2025. Review of facility census data indicated that on May 19, 2025, the facility census was 85, which required 5.67 NA's during the night shift. Review of the nursing time schedules revealed 5.33 NA's provided care on the night shift on May 19, 2025.
No additional excess higher-level staff were available to compensate for these deficiencies.
Interview with the Nursing Home Administrator on May 21, 2025, at 2:56 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 07/07/2025
1)Open shifts are put out to all staff well in advance for facility staff and agency to pick up. Facility offers bonuses for pick up shifts, overtime (OT), agency use and trades to help cover any open shifts including call offs. The facility recruits daily and has competitive rates for staff to come and work for us. We offer Licensed practical nurses to work down as nurse aides (NA) when open shifts are available.
2) Facility offers bonuses for pick up shifts, OT, agency use and trades to help cover any open shifts. Open shifts are put out to all staff well in advance for facility staff and agency to pick up. The facility recruits daily and has competitive rates for staff to come and work for us. We offer Licensed practical nurses to work down as aides when open shifts are available.
3) Administrator and/or designee will review the minimum staffing requirements with staffing coordinator, Human Resource (HR) and nursing administration to ensure we are doing all we can to meet NA ratios
4) Staffing Coordinator and/or designee will audit daily NA-to-resident staffing ratios to ensure we are meeting the requirements x 1 month
Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.
|
|
