(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations:
Based on review of staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on day shift for one out of seven days (April 29, 2024) and failed to ensure one nurse aide per 12 residents on evening shift for three out of seven days reviewed (April 26, 27, and 28, 2024).
Findings Include:
Review of the facility provided staffing ratio information on April 29, 2024, during the day shift, revealed a census of 130 residents. The information also revealed 9 nurse aide staff working during that shift; therefore, not meeting the minimum number of nurse aides required for the facility census of residents on that shift.
Review of the facility provided staffing ratio information for April 26, 2024, through April 28, 2024, during the evening shift, revealed a census of 129-131 residents. The information also revealed a nurse aide ratio of 10.82 on April 26, 2024, a nurse aide ratio of 9.41 on April 27, 2024, and a nurse aide ratio of 7.88 on April 28, 2024; therefore, the facility did not meet the minimum nurse aide ratio required for the facility census of residents on those shifts.
During an interview with the Nursing Home Administrator on May 21, 2024, at 11:15 AM, she confirmed the facility had not met the required nurse aide ratio on April 26, through April 29, 2024, on four shifts.
| | Plan of Correction - To be completed: 06/17/2024
1. Nurse aide ratios were adjusted to ensure a 1:12 ratio on days and Evenings and 1:20 on night shift.
2. Nurse aid ratios will be scheduled at a 1:12 ratio for days and evening Shifts and 1:20 for night
shifts. Weekly labor management calls with Human Resource Director, NHA, DON and scheduler to review current
and expected staffing needs are ongoing. Three RNs participate in an on-call
rotation to be notified of any call outs that fall below the state minimum ppd and nurse and CNA
ratios.
3. Education has been provided to the scheduler to ensure a 1:12 ratio is met daily
and 1:20 for nights per regulations. Education has also been provided to clinical staff about the
attendance policy and the consequences of the attendance infractions.
4. DON/designee will do random audits of 5 shifts per week for 3 weeks
to ensure compliance. Results will be submitted to QAPI to determine if audits will continue
beyond 3 weeks.
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