Observations:
Based on review of the 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 for the evening shift for one of 21 days reviewed (2/10/24); and failed to ensure a minimum of one NA per 20 residents for the overnight shift for three of 21 days reviewed (3/03/24, 3/04/24, and 3/05/24).
Findings include:
Review of facility staffing ratio information for the three weeks reviewed ( 1/14/24 through 1/20/24, 2/04/24 through 2/10/24 and 2/28/24 through 3/05/24) , revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
2/10/24 census of 56 residents 3.82 NAs worked and 4.67 were required.
Review of facility staffing ratio information from the three weeks reviewed as above, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
3/03/24 census of 49 residents 2.19 NAs worked and 2.45 were required.
3/04/24 census of 49 residents 2.37 NAs worked and 2.45 were required.
3/05/24 census of 51 residents 1.62 NAs worked and 2.55 were required.
During an interview on 3/08/24, at 11:57 a.m. the Nursing Home Administrator confirmed that the facility had not met the minimum staff to resident ratio for NAs on the above dates and shifts.
| | Plan of Correction - To be completed: 04/10/2024
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Grove Manor agrees with the allegations and citations listed on the statement of deficiencies. Grove Manor maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Grove Manor's written credible allegation of compliance.
By submitting this plan of correction, Grove Manor does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Grove Manor reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
There were no negative care impacts to any resident as a result of the identified concern. The
overall daily per patient day (PPD) staffing numbers remained over the state minimum. The
facility cannot retroactively correct this finding.
The Director of Nursing will provide education to the nursing management team on the updated nurse aide to resident staffing ratios and hours per resident day. The facility will continue to advertise for, interview, and select its own staff. The Nursing Home Administrator and/or Director of
Nursing are negotiating contract revisions to improve part time and as needed for certified nursing aide staffing support.
The Director of Nursing or Designee will audit staffing ratios two times per day, five times per week for four weeks,
then re-evaluate the need to increase or decrease monitoring to verify that all measures are being taken to meet licensed certified nursing aide staffing ratios. The Nursing Home Administrator and/or Director of Nursing will utilize recommended staffing grid provided by The Department of Health.
Audit findings will be submitted to the Quality Assurance and Performance Improvement
Committee for further review and recommendations.
|
