(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 facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on day shift, one NA per 12 residents on evening shift, and one NA per 20 residents on the overnight shift, for 20 of 21 days reviewed for staffing ratio.
Findings include:
Review of facility census on the following shifts revealed that the facility failed to meet the minimum required NA ratio.
Review of 21 days of nursing staffing documentation from 8/1/23 through 8/7/23, 12/30/23 through 1/5/24, and 2/29/24 through 3/6/24, for the day shift revealed:
8/3/23, facility census of 45 residents, 3.67 NAs scheduled and 3.75 were required.
8/5/23, facility census of 46 residents, 3.63 NAs scheduled and 3.83 were required.
8/6/23, facility census of 45 residents, 3.60 NAs scheduled and 3.75 were required.
12/30/23, facility census of 42 residents, 3.03 NAs scheduled and 3.50 were required.
12/31/23, facility census of 42 residents, 3.03 NAs scheduled and 3.50 were required.
1/1/24, facility census of 42 residents, 3.03 NAs scheduled and 3.50 were required.
1/2/24, facility census of 42 residents, 3.00 NAs scheduled and 3.50 were required.
1/3/24, facility census of 42 residents, 3.00 NAs scheduled and 3.50 were required.
1/4/24, facility census of 42 residents, 3.10 NAs scheduled and 3.50 were required.
1/5/24, facility census of 42 residents, 3.00 NAs scheduled and 3.50 were required.
2/29/24, facility census of 40 residents, 3.10 NAs scheduled and 3.33 were required.
3/1/24, facility census of 40 residents, 3.07 NAs scheduled and 3.33 were required.
3/2/24, facility census of 40 residents, 2.97 NAs scheduled and 3.33 were required.
3/3/24, facility census of 40 residents, 3.03 NAs scheduled and 3.33 were required.
Review of 21 days of nursing staffing documentation from 8/1/23 through 8/7/23, 12/30/23 through 1/5/24, and 2/29/24 through 3/6/24, for the evening shift revealed:
8/1/23, facility census of 45 residents, 3.53 NAs scheduled and 3.75 were required.
8/3/23, facility census of 45 residents, 3.03 NAs scheduled and 3.75 were required.
8/4/23, facility census of 45 residents, 3.57 NAs scheduled and 3.75 were required.
8/6/23, facility census of 45 residents, 3.33 NAs scheduled and 3.75 were required.
8/7/23, facility census of 47 residents, 3.07 NAs scheduled and 3.92 were required.
1/1/24, facility census of 42 residents, 3.07 NAs scheduled and 3.50 were required.
1/2/24, facility census of 42 residents, 3.07 NAs scheduled and 3.50 were required.
1/3/24, facility census of 42 residents, 3.07 NAs scheduled and 3.50 were required.
1/4/24, facility census of 42 residents, 3.07 NAs scheduled and 3.50 were required.
1/5/24, facility census of 43 residents, 3.53 NAs scheduled and 3.58 were required.
3/2/24, facility census of 40 residents, 2.87 NAs scheduled and 3.33 were required.
3/3/24, facility census of 40 residents, 3.03 NAs scheduled and 3.33 were required.
3/4/24, facility census of 40 residents, 3.00 NAs scheduled and 3.33 were required.
3/5/24, facility census of 40 residents, 3.10 NAs scheduled and 3.33 were required.
Review of 21 days of nursing staffing documentation from 8/1/23 through 8/7/23, 12/30/23 through 1/5/24, and 2/29/24 through 3/6/24, for the overnight shift revealed:
8/1/23, facility census of 45 residents, 2.07 NAs scheduled and 2.25 were required.
8/2/23, facility census of 46 residents, 2.10 NAs scheduled and 2.30 were required.
8/4/23, facility census of 45 residents, 2.13 NAs scheduled and 2.25 were required.
8/5/23, facility census of 46 residents, 2.13 NAs scheduled and 2.30 were required.
8/7/23, facility census of 47 residents, 2.03 NAs scheduled and 2.35 were required.
12/30/23, facility census of 42 residents, 2.00 NAs scheduled and 2.10 were required.
1/4/24, facility census of 42 residents, 2.07 NAs scheduled and 2.10 were required.
1/5/24, facility census of 43 residents, 2.00 NAs scheduled and 2.15 were required.
3/1/24, facility census of 40 residents, 1.83 NAs scheduled and 2.00 were required.
3/5/24, facility census of 40 residents, 1.97 NAs scheduled and 2.00 were required.
During an interview on 3/8/24, at approximately 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to meet the minimum ratio requirements on the above dates and shifts.
| | Plan of Correction - To be completed: 04/23/2024
The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. The facility will continue to take measures to adequately provide staff to meet the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, increase the ad exposure of sign on bonuses.
The Director of Nursing or designee will continue to educate minimum staffing ratios to RN supervisors, HR and scheduling who are responsible to maintain adequate staffing and ratios.
The director of nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled.
Should a call off occur, Highland View will initiate it's procedure of contacting part time and per diem employees; offer overtime and shift pick up bonuses to all applicable nursing personnel as well as contacting all contracted staffing agencies regarding the open shift(s).
The Nursing Home Administrator or designee will consider admission intake based on ratios and minimum PPD expectations.
These audits will be conducted weekly until cleared by Quality Assurance and Process Improvement meeting.
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