Failure to Meet RN Staffing Requirements on Overnight Shifts
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum of one registered nurse (RN) per 250 residents during all shifts. This deficiency was identified during a review of nursing staffing hours and staff interviews, which revealed that the facility did not meet the required RN-to-resident ratio on the overnight shift for eight out of the 21 days reviewed. Specifically, on several dates between November 2024 and February 2025, the facility had fewer RNs than required, with some nights having no RN present at all. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to meet the regulatory RN-to-resident ratios during an interview on February 6, 2025.
Plan Of Correction
1. Facility can not retroactively correct. 2. Facility can not retroactively correct. Facility will continue to recruit and retain RN staff through a variety of services. 3. NHA/Designee will educate the scheduler and DON on state regulation. DON or designee will conduct review of staffing deployment assignments daily to ensure the staffing ratio is being met for a period of 4 weeks and a weekly review x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.