(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 time schedules, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day, one nurse aide per 12 residents during the evening, and one nurse aide per 20 residents overnight on nine days for three weeks' staffing reviewed (Weeks of December 24, 2023, January 7, 2024, and February 11, 2024).
Review of the staffing for the weeks of December 24, 2023, January 7, 2024, and February 11, 2024 revealed the following dates and shifts did not meet the minimum requirements for nurse aide staffing ratios:
December 24, 2023, on the day, evening, and night shifts December 25, 2023, on the day and evening shifts December 26, 2023, on the night shift December 27, 2023, on the day and evening shifts December 28, 2023, on the evening shift January 7, 2024, on the day and evening shifts January 9, 2024, on the evening shift January 11, 2024, on the evening shift January 12, 2024, on the day, evening, and night shifts
Interview with the Nursing Home Administrator and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.
| | Plan of Correction - To be completed: 04/15/2024
No residents were adversely impacted due to the HPPD and nursing aide assignment.
The Staffing Scheduler, Director of Nursing, and Nursing Home Administrator meet each morning to review the projected HPPD for the upcoming days and to review the staffing ratios each day.
Our staff will be contacted to pick up extra shifts as necessary. Also, nursing agencies will be used to ensure that we have the correct staffing ratios.
Audits will be conducted by the Nursing Home Administrator or designee daily for the next three months to ensure that we are meeting the staffing ratio requirements. Results of the audits will be forwarded to the QAPI committee for review and recommendations.
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