(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.
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Observations:
Based on staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on day shift for five of 7 days reviewed (October 9, 10, 11, 14, and 15, 2024), one NA per 11 residents on evening shift for five of 7 days reviewed (October 9, 10, 11, 12, and 13, 2024), and one NA per 15 residents on night shift for three of 7 days reviewed (October 12, 13, and 15, 2024) as calculated by full time equivalent (FTE - Number of staff required calculated by determining the required number of hours of full time shifts worked to meet the minimum staff to resident ratio).
Findings include:
Review of staffing information for the day shift of October 9, 2024, revealed a resident census of 116, which resulted in a minimum NA FTE of 11.60; submitted information revealed the facility provided 10.97.
Review of staffing information for the evening shift of October 9, 2024, revealed a resident census of 117, which resulted in a minimum NA FTE of 10.64; submitted information revealed the facility provided 10.10.
Review of staffing information for the day shift of October 10, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.23.
Review of staffing information for the evening shift of October 10, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 8.07.
Review of staffing information for the day shift of October 11, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.53.
Review of staffing information for the evening shift of October 11, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 8.57.
Review of staffing information for the evening shift of October 12, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 10.82; submitted information revealed the facility provided 9.80.
Review of staffing information for the night shift of October 12, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 7.93; submitted information revealed the facility provided 7.50.
Review of staffing information for the evening shift of October 13, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 10.73; submitted information revealed the facility provided 9.27.
Review of staffing information for the night shift of October 13, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 7.87; submitted information revealed the facility provided 6.97.
Review of staffing information for the day shift of October 14, 2024, revealed a resident census of 118, which resulted in a minimum NA FTE of 11.80; submitted information revealed the facility provided 9.37.
Review of staffing information for the day shift of October 15, 2024, revealed a resident census of 119, which resulted in a minimum NA FTE of 11.90; submitted information revealed the facility provided 11.33.
Review of staffing information for the night shift of October 15, 2024, revealed a resident census of 120, which resulted in a minimum NA FTE of 8.00; submitted information revealed the facility provided 7.47.
An email communication received from the Nursing Home Administrator on October 16, 2024, at 9:51 AM, indicated that she was aware the facility was still not meeting state mandated nurse aide ratios.
An email communication received from the Director of Nursing on October 16, 2024, at 4:19 PM, indicated that the expectation is for the facility to be staffed at state mandated ratios of nurse aides.
| | Plan of Correction - To be completed: 11/07/2024
1. Facility cannot retroactively correct this concern
2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing ratios will be audited for any grievances related to staffing.
3. Re-education was previously completed with nursing staff on staffing and minimum requirements. Facility continues to partner with company in recruiting for the CNA classes. Will continue to offer bonuses when ratios are below minimum, and mandate as needed when call outs and absences occur. Facility will re-evaluate agency rates to increase CNA staffing
4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.
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