(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 four out of 14 days reviewed (June 18, 19, 25 and 29, 2024); failed to ensure one Nurse Aide per 12 residents on evening shift for five out of 14 days reviewed (June 22, 23, 28, 29, and 30, 2024), and failed to ensure one nurse aide per 20 residents on the night shift for two out of 14 days reviewed (June 24, 25, 2024) as calculated by full time equivalent (FTE - number of shifts worked by staff calculated by the total number of hours worked divided by the length of shift) hours.
Findings Include:
Review of staffing information provided by the facility for June 17 to 30, 2024, revealed the following census, required Nurse Aide FTE based on facility census, and provided Nurse Aide FTE provided during the specified shift:
June 18, 2024, day shift census of 138, Nurse Aide (NA) FTE requirement of 11.50, facility provided 10.65.
June 19, 2024, day shift census of 136, NA FTE requirement of 11.33, facility provided 11.09.
June 22, 2024, evening shift census of 138, NA FTE requirement of 11.50, facility provided 10.05.
June 23, 2024, evening shift census of 137, NA FTE requirement of 11.42, facility provided
11.39.
June 24, 2024, night shift census of 136, NA FTE requirement of 6.80, facility provided 5.52.
June 25, 2024, day shift census of 135, NA FTE requirement of 11.25, facility provided 10.45.
June 25, 2024, night shift census of 135, NA FTE requirement of 6.75, facility provided 6.55.
June 28, 2024, evening shift census of 137, NA FTE requirement of 11.42, facility provided 11.19.
June 29, 2024, day shift census of 139, NA FTE requirement of 11.58, facility provided 9.75.
June 29, 2024, evening shift census of 139, NA FTE requirement of 11.58, facility provided 9.87.
June 30, 2024, evening shift census of 138, NA FTE requirement of 11.50, facility provided 9.63.
During a staff interview on July 5, 2024, at approximately 11:30 AM, the Nursing Home Administrator and Director of Nursing confirmed that the facility was not in compliance with the Nurse Aide ratios on the aforementioned dates.
| | Plan of Correction - To be completed: 07/22/2024
1. Nursing ratios were adjusted to ensure a 1:10 ratio on Days, 1: 11 on Evenings and 1:15 on
night shift.
2. Nursing ratios will be scheduled at a 1:10 ratio for days, 1:11 on evening shifts and 1:15 for
night shifts. Weekly labor management calls with HRD, 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 and HRD to ensure a 1:10 ratio is met on day
shift, 1:11 for evening shift and 1:15 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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