(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 nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift for six of 14 days, failed to ensure a minimum of one NA per 12 residents on the evening shift for five of 14 days, and failed to ensure a minimum of one NA per 20 residents on the overnight shifts for one of 14 days (24-hour periods) for May 26 through June 8, 2024, and failed to provide one NA per 10 residents on the day shift for two of seven days, failed to ensure a minimum of one NA per 11 residents on the evening shift for one of seven days, and failed to ensure a minimum of one NA per 15 residents on the overnight shift for six of seven days for July 7-13, 2024.Findings Include:Review of facility census data indicated that on May 26, 2024, the facility census was 75, which required 6.25 (75 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 6.20 NA's provided care on the evening shift on May 26, 2024. On May 28, 2024, the facility census was 75, which required 6.25 NA's during the day shift; however, review of the time schedule revealed that 6.03 NA's provided care on the day shift. On May 29, 2024, the facility census was 76, which required 6.33 NA's during the day shift; however, review of the time schedule revealed that 6.03 NA's provided care on the day shift. The evening shift census of 76 required 6.33 NA's; however, review of the time schedule revealed that 3.93 NA's provided care on the evening shift. The night shift census of 76 required 3.80 NA's; however, review of the time schedule revealed that 3.33 NA's provided care on the night shift.On May 30, 2024, the facility census was 76 during the day shift, which required 6.33 NA's during the day shift; however, review of the time schedule revealed that 5.58 NA's provided care on the day shift. The evening census increased to 78, which required 6.50 NA's to provide care on the evening shift; however, review of the time schedule revealed that 4.92 NA's provided care on the evening shift.On June 1, 2024, the facility census was 78 during the day shift, which required 6.50 NA's; however, review of the time schedule revealed that 5.47 NA's provided care on the day shift. The evening census was 78, which required 6.50 NA's to provide care; however, review of the time schedule revealed that 5.30 NA's provided care on the evening shift.On June 2, 2024, the facility census was 78 during the evening shift, which required 6.50 NA's; however, review of the time schedule revealed that 6.50 NA's provided care on the evening shift.On June 4, 2024, the facility census was 78 during the evening shift, which required 6.50 NA's; however, review of the time schedule revealed that 5.90 NA' provided care on the evening shift.On June 7, 2024, the facility census was 78 during the evening shift, which required 6.50 NA's; however, review of the time schedule revealed that 6.07 NA's provided care on the evening shift.ON July 7, 2024, the facility census was 79 during the evening shift, which required 5.27 NA's; however, review of the time schedule revealed that 4.13 NA's provided care during the night shift.On July 8, 2024, the facility census was 79 during the evening shift, which required 5.27 NA's; however, review of the time schedules revealed that 5.07 NA's provided care during the night shift.On July 9, 2024, the facility census was 77 during the night shift, which required 5.13 NA's; however, review of the time schedules revealed that 5.00 NA's provided care during the night shift.On July 10, 2024, the facility census was 81 during the day shift, which required 8.10 NA's; however, review of the time schedules revealed that 8.0 NA's provided care during the day shift.On July 11, 2024, the facility census was 81 during the night shift, which required 5.40 NA's; however, review of the time schedules revealed that 6.73 NA's provided care during the night shift.On July 12, 2024, the facility census was 81 during the night shift, which required 5.40 NA's; however, review of time schedules revealed that 5.0 NA's provided care during the night shift.On July 13, 2024, the facility census was 80 during the day shift, which required 8.0 NA's; however, review of the time schedules revealed that 7.33 NA's provided care during the day shift. The facility census was 80 during the night shift, which required 5.33 NA's; however, review of time schedules revealed that 5.00 NA's provided care during the night shift.No additional excess higher-level staff were available to compensate for these deficiencies.Interview with the Director of Nursing on August 2, 2024 at 3:01 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 08/20/2024
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1.Facility unable to correct the staffing hours for the cited six of 14 days on daylight, 5 of 14 days on evening shift and 1 of 14 days on night shift from May 26 through June 8. The facility is unable to correct the staffing hours for the cited 2 of seven days of day shift, 1 of 7 days on evening shift and 6 of 7 days on night shift from July 7-13. No significant outcomes noted.
2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy.
3.The Administrator or designee will audit the direct care staffing five times per week to ensure regulatory compliance. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical management staff will consider delaying, limiting new admissions, or placing admissions on hold. Nursing staff including licensed nurses and nursing management will be asked to fill openings as needed.
4. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations
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