Observations:
Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for three 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 1:15 on the night shift based on the facility's census.
July 9, 2024 - 7.63 nurse aides on the night shift, versus the required 8.87 for a census of 133.
July 12, 2024 - 7.63 nurse aides on the night shift, versus the required for 8.93 for a census of 134.
July 15, 2024 - 8.00 nurse aides on the night shift, versus the required for 8.93 for a census of 134.
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 17, 2024, at approximately 2:45 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 08/27/2024
Elan Skilled Nursing and Rehab (the "Home") submits this Plan of Correction under procedures established by the Department of Health to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.
Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
The facility cannot retroactively correct the nurse aide ratio not met on three dates, 7/9/24, 7/12/24, and 7/15/24. There were no adverse effects to residents on the identified dates. Average hours per resident days for the three-week period reviewed was 3.35.
The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The facility will ensure that shift ratios are met on every shift.
Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Scheduled shift staffing ratios are reviewed by the DON, Administrator, or designee, daily and before the weekend. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.
The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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