(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.
|
Observations:
Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on day and evening shifts for three of seven days reviewed (February 24, 25, and 26, 2024).
Findings include:
Review of facility provided staffing ratio information for February 23 through 29, 2024, on day shift, revealed a resident census of 104-105 residents. The information also revealed a Nurse Aide ratio of 7.30 and 7.13 worked during the day shift on February 24 and 25, 2024; therefore, the facility did not meet the minimum nurse aide ratio required for the facility census of residents on those shifts.
Review of facility provided staffing ratio information for February 23 through 29, 2024, on evening shift revealed a resident census of 104-105 residents. The information also revealed a Nurse Aide ratio of 7.23 worked during the evening shift on February 26, 2024; therefore, the facility did not meet the minimum nurse aide ratio required for the facility census of residents on that shift.
During an interview with the Director of Nursing on March 8, 2024, at 9:00 AM, she confirmed that the facility did not meet the required nurse aide to resident staffing ratio.
| | Plan of Correction - To be completed: 03/28/2024
The facility will ensure at least minimum required ratios for CNAs of at least one nurse aide per 12 residents on day and evening shifts.
The facility will exhaust all appropriate measures to meet CNA staffing ratios including but not limited to use of per-diem staff, agency use, bonuses and other incentives to encourage staff to fill vacant shifts and call offs, as well as continued recruitment and retention efforts.
Nursing Home Administrator/designee will educate Facility Scheduler and Director of Nursing on requirements of 5510 including importance of meeting requirements of nurse aide staffing ratios.
The Nursing Home Administrator/designee will audit daily CNA staffing ratios for compliance. These audits will be conducted weekly for 4 weeks and monthly for two months. Results of these audits will be reviewed through the Quality Assurance Performance Improvement Committee for additional recommendations as necessary.
|
|
