(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 facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on day shift, for three of three weeks reviewed and the facility failed to ensure a minimum of one nurse aide per 11 residents on evening shift for one of three weeks reviewed (week of August 1, 2024, August 8, 2024, and August 15, 2024).
Findings include:
Review of the week of August 1, 2024, revealed the following dates on day shift did not meet the requirements of one nurse aide per 10 residents:
August 1, 2024, August 3, 2024, and August 4, 2024.
Review of the week of August 8, 2024, revealed the following dates on day shift did not meet the requirements of one nurse aide per 10 residents:
August 10, 2024, and August 11, 2024.
Review of the week of August 15, 2024, revealed the following dates on day shift did not meet the requirements of one nurse aide per 10 residents:
August 15, 2024, August 16, 2024, August 18, 2024, August 19, 2024, and August 21, 2024.
Review of the week of August 1, 2024, revealed the following dates on evening shift did not meet the requirements of one nurse aide per 11 residents:
August 21, 2024.
Interview conducted with Nursing Home Administrator on August 30, 2024, at 10:50 a.m. when the above information was presented.
| | Plan of Correction - To be completed: 10/07/2024
1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
3. All Nursing Staff will be re-educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to the QAPI for review and revision as needed.
|
|
