(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 review of facility staffing and staff interview it was determined the facility failed to meet the minimum full time equivalent hours for Nurse Aides, that could affect resident health and safety, on five of 21 days (11/24/23, 11/25/23, 1/21/24, 1/22/24, and 1/23/24.)
Findings Include:
Review of facility provided staffing for the period of 7/2/23 through 7/8/23, 11/19/23 through 11/25/23, and 1/21/24 through 1/27/24, revealed the facility did not meet the minimum full time equivalent (FTE - a unit of time measurement used to determine the full time hours, 7.5 or 8 hours equal 1 staff, worked by an employee) hours for Nurse Aides (NA) on the following days and shifts:
11/24/23: Facility census was 50. The afternoon shift needed 4.17 FTE NA hours, the facility had scheduled 4.00 FTE NA hours. 11/25/23: Facility census was 52. The day shift needed 4.33 FTE NA hours, the facility had scheduled 4.0 FTE NA hours. 1/21/22: Facility census was 52. The day shift needed 4.33 FTE NA hours, the facility had scheduled 4.0 FTE NA hours. 1/22/24: Facility census was 51. The afternoon shift needed 4.17 FTE NA hours, the facility had scheduled 4.13 FTE NA hours. 1/23/24: Facility census was 51. The afternoon shift needed 4.25 FTE NA hours, the facility had scheduled 4.13 FTE NA hours.
During an interview on 2/7/24, the Nursing Home Administrator confirmed the facility failed to meet the FTE NA hours, that could affect resident health and safety.
| | Plan of Correction - To be completed: 03/11/2024
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Facility is unable to retroactively correct staffing ratio reporting or errors. A 2 week look back will be performed by scheduler or designee to review opportunities for reporting and proactive planning opportunities of nurse staffing ratios. The Administrator or designee will create a process moving forward of new staff recruitment in addition to ensuring hours are accounted for and reported in correct job categories. Staff education will be conducted by Director of Nursing or designee on staffing ratios and process to calculate compliance in the event there is an unexpected change in the schedule. Administrator, Director of Nursing or designee will audit ratio schedule report prior to scheduled day to ensure ratios are in compliance daily for 7 days, weekly for 3 weeks and monthly for 2 months. Report of recruitment attempts, and ratio reporting will be reported to monthly QAPI Committee. (Quality Assurance Process Improvement) by Administrator or designee. The QAPI committee will decide after initial audit cycle regarding discontinuation of audits due to substantial compliance or continuation of audits.
|
|