(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 documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on both day and evening shifts, and one NA per 20 residents on the overnight shift, for five of 21 days reviewed for staffing ratio (11/24/23, 11/25/23, 12/16/23, 12/17/23, and 12/18/23)
Findings include:
Review of 21 days of nursing staffing documentation for day shift revealed:
On 11/25/23, facility census of 61 residents, five NA scheduled and six were required. On 12/18/23, facility census of 67 residents, five NA scheduled and six were required.
Review of 21 days of nursing staffing documentation for evening shift revealed:
On 11/24/23, facility census of 61 residents, five NA scheduled and six were required. On 12/16/23, facility census of 68 residents, four NA scheduled and six were required. On 12/17/23, facility census of 68 residents, five NA scheduled and six were required.
Review of 21 days of nursing staffing documentation for overnight shift revealed:
On 12/16/23, facility census of 68 residents, three NA scheduled and four were required.
During an interview on 12/21/23, at 10:04 a.m. the Staff Scheduler confirmed that the facility failed to meet the minimum ratio requirements on the above dates and shifts.
| | Plan of Correction - To be completed: 02/15/2024
1) The facility will meet minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels. 2) The Nursing Home Administrator will educate the DON, ADON, Nursing Supervisors and Scheduler on required ratios to ensure facility is meeting ratios. 3) System changes to help ensure proper staffing ratios are met include reviewing potential admissions to ensure proper census levels, increase agency use as needed, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment. 4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed weekly for one month, biweekly for one month and monthly for 3 months. Audits will be reviewed as part of the facilities QAPI committee and monitored for tracking and trending.
|
|