(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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day on three of 21 day shifts reviewed (one per 10 as of July 1, 2024); a minimum of one nurse aide per 12 residents on 12 of 21 evening shifts reviewed (one per 11 as of July 1, 2024); and failed to ensure a minimum of one nurse aide per 20 residents on one of 21 overnight shifts reviewed.
Findings include:
Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:
Day shift:
December 25, 2023, 5.78 NAs for a census of 83, requires 6.92 NAs. December 29, 2023, 5.84 NAs for a census of 85, requires 7.08 NAs.
March 18, 2024, 5.16 NAs for a census of 78, requires 6.50 NAs.
Evening shift:
October 2, 2023, 6.03 NAs for a census of 82, requires 6.83 NAs. October 3, 2023, 6.06 NAs for a census of 83, requires 6.92 NAs. October 4, 2023, 6.31 NAs for a census of 85, requires 7.08 NAs. October 5, 2023, 6.31 NAs for a census of 84, requires 7 NAs. October 6, 2023, 6.75 NAs for a census of 84, requires 7 NAs.
December 26, 2023, 6.31 NAs for a census of 83, requires 6.92 NAs. December 27, 2023, 6.34 NAs for a census of 85, requires 7.08 NAs. December 30, 2023, 6.94 NAs for a census of 85, requires 7.08 NAs.
March 15, 2024, 6.78 NAs for a census of 82, requires 6.83 NAs. March 16, 2024, 6.66 NAs for a census of 81, requires 6.75 NAs. March 17, 2024, 6.41 NAs for a census of 81, requires 6.75 NAs. March 21, 2024, 6.22 NAs for a census of 81, requires 6.75 NAs.
Overnight shift:
December 28, 2023, 4.13 NAs for a census of 85, requires 4.25 NAs.
This information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing Home on March 22, 2024, at 1:20 PM.
| | Plan of Correction - To be completed: 04/30/2024
1. 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 by utilization of agency staff and continuing nurse aide training on site.
2. The Director of Nursing/designee will schedule adequate staffing to meet nurse aide to resident ratios. Schedules will be monitored daily during daily staffing meeting.
3. NHA/designee will audit schedules prior to shift start for adequate staffing.
4. Audits will be completed to ensure nurse aide to resident ratios are met 3xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.
5. 4/30/2023
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