(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for three of five days reviewed.
Findings include:
Review of nursing schedules for five days from July 3 through July 7, 2024, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day shift (7:00 a.m. to 3:00 p.m.) on July 7, 2024.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 3 and July 5, 2024.
In an interview on July 8, 2024, at 11:00 a.m., the Administrator confirmed that the facility did not meet the minimum nurse aide to resident ratios for the above-mentioned dates.
| | Plan of Correction - To be completed: 08/20/2024
1. Facility cannot retroactively correct staffing patterns for historic dates.
2. DON, ADON, and scheduler re-educated by NHA on 7/8/24. A process is in place to monitor and review staffing patterns including per patient day hours and ratios per shift to ensure adequate coverage. When call-offs occur, facility to work with staffing agencies and have a list of "as needed" team members. Facility offers additional compensation to secure coverage for staff as necessary.
3. Facility to continue to follow protocol and established process to monitor the schedule and review staffing patterns of ratios per shift to ensure adequate coverage with the regulatory requirements and to safely care for residents.
4. Daily audits of schedule including ratios per shift will be reviewed 5X week x4 weeks, weekly x4, then twice monthly x2 months, or until substantial compliance. Corrective action plan and audits will be monitored through our Quality Assurance Performance Improvement Committee.
5. Date of compliance 8/20/2024
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