(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.
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Observations:
Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 11 shifts out of 21 shifts reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift based on the facility's census.
July 11, 2024 - 3.38 nurse aides on the day shift, versus the required 4.10 for a census of 41.
July 14, 2024 - 3.69 nurse aides on the night shift, versus the required for 3.90 for a census of 39.
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:11 on the evening shift based on the facility's census.
July 14, 2024 - 3.00 nurse aides on the evening shift, versus the required for 3.55 for a census of 39.
July 17, 2024 - 3.00 nurse aides on the evening shift, versus the required for 3.45 for a census of 38.
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:15 on the night shift based on the facility's census.
July 11, 2024 - 2.00 nurse aides on the night shift, versus the required 2.80 for a census of 42.
July 12, 2024 - 2.00 nurse aides on the night shift, versus the required 2.67 for a census of 40.
July 13, 2024 - 1.44 nurse aides on the night shift, versus the required 2.60 for a census of 39.
July 14, 2024 - 2.50 nurse aides on the night shift, versus the required 2.60 for a census of 39.
July 15, 2024 - 1.56 nurse aides on the night shift, versus the required 2.67 for a census of 40.
July 16, 2024 - 2.50 nurse aides on the night shift, versus the required 2.60 for a census of 39.
Ju;y 17, 2024- 2.00 nurse aides on the night shift, versus the required 2.53 for a census of 38.
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Nursing Home Administrator on July 18, 2024, at approximately 2:45 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates and shifts.
| | Plan of Correction - To be completed: 10/31/2024
The facility cannot retroactively correct past staffing. No issues were noted with residents.
The facility cannot retroactively correct past staffing issues. Moving forward the facility will continue to make good faith effort utilizing internal resources in the event of unforeseen staffing requirement deficits to make a good faith effort to ensure CNA staffing mandate is followed.
To prevent this from reoccurring the RVPO/designee will reeducate the NHA/DON on updated staffing regulations regarding staffing ratios and ensure a staffing meeting is held between the Don and NHA 5 days a week to ensure staffing ratios are met.
To monitor and maintain ongoing compliance the NHA/designee will audit deployment sheets to ensure the facility is staffed in accordance with the mandated requirements 5X's weekly X4, then weekly X2 months. The results of the audits will be forwarded to facility QAPI committee for further review and recommendations.
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