Observations:
Based on review of nursing time schedules and staff interview, it was determined that the facility administrative staff failed to provide a minimum of one nursing assistant per 12 residents during the evening shift on one of seven days (3/9/24).
Findings include:
Review of facility census data and nursing time schedules from 3/4/24 through 3/10/24, revealed the following nursing assistant staffing shortage:
Evening shift:
3/9/24 census 106 59.90 actual hours 66.25 hours required.
During an interview on 3/11/24, at 12:20 p.m. the Nursing Home Administrator confirmed the above staffing shortage and that the facility failed to provide nursing assistants as required.
| | Plan of Correction - To be completed: 04/22/2024
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Hempfield Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Hempfield Manor credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:12 nurse aide for evenings by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily for 3x weekly to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Weekend and Shift Supervisors will immediately contact DON/ADON for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution.
Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor has instituted a Hiring Bonus for 3-11 evening shift aide applicants. Hempfield Manor has raised all wages for certified aides. Hempfield Manor also offers extra pay incentives to current staff to cover extra shifts. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months until compliance is achieved. Results will be reported on a monthly basis during the monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
|
