(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 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 both day and evening shift and a minimum of one nurse aide per 20 residents during the night shift for five of seven days reviewed (March 19, 21, 22, 24, and 25, 2024).
Findings Include:
Review of the facility resident census and submitted staffing documentation revealed that the facility failed to meet the required Nurse Aide to resident ratios, as determined by the minimum hours required per resident census, and/or the minimum Full Time Equivalent (FTE - number of staff required to meet the required hours) for the following days and shifts:
March 19, 2024, during the evening shift the required Nurse Aide Ratio was 11.42, the facility provided 10.53.
March 21, 2024, during the day shift the required Nurse Aide Ratio was 11.33, the facility provided 10.33.
March 21, 2024, during the night shift the required Nurse Aide Ratio was 6.80, the facility provided 6.73.
March 22, 2024, during the evening shift the required Nurse Aide Ratio was 11.50, the facility provided 10.80.
March 24, 2024, during the day shift the required Nurse Aide Ratio was 11.50, the facility provided 11.00.
March 24, 2024, during the night shift the required Nurse Aide Ratio was 6.95, the facility provided 5.87.
March 25, 2024, during the day shift the required Nurse Aide Ratio was 11.50, the facility provided 10.00.
On March 27, 2024, at 10:58 AM, Employee 1 (Scheduling and Payroll Manager) confirmed that the facility did not meet the ratios, due in part to call offs.
On March 27, 2024, at 3:17 PM, the Nursing Home Administrator stated the facility is continuing to work on their staffing.
| | Plan of Correction - To be completed: 04/30/2024
1. No residents or staff were harmed by deficient practice.
2. Daily staffing and census calls are held to ensure sufficicent staff to provide care and meet minimum nurse aide staffing ratio of one nurse aide per 12 residents on dayshift, one nurse aide per 12 residents on evening shift and one nurse aide per 20 residnet on overnight shift.
3. To ensure deficient practice does not re-occur, the NHA/designee educated the DON, RN Supervisors, Unit Managers, and Scheduler on PA State Regulation 5510. A weekly meeting with recruiter, Administrator, Scheduler and HR support is in place to develop strategies for increased applicant flow.
A daily meeting with Admin, DON, Scheduler to determine staffing needs for the upcoming days. Communication to Agency Service Manager to address their staff that called off or upcoming needs.
A daily meeting with Admin, DON and Admissions to determine ability to accept admissons based on staffing is in place.
Scheduler provided RN Supervisor a list of employees to contact when call offs occur and their phone numbers. Scheduler and RN Supervisors educated on the importance to work to cover call offs.
4.DON/designee will complete random audits of five shifts per week for four weeks to ensure compliance. Results of audits will be reported to QA Committee for review and recommendations.
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