Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing ratio of one Registered Nurse (RN) per 250 residents during all shifts on two specific days. On January 24 and 25, 2025, during the overnight shifts, the facility had 109 residents but did not have the required RN staffing levels, with ratios of 0.88 and 0.81 RNs, respectively. This deficiency was confirmed through a review of staffing documents and an interview with the Director of Nursing, who acknowledged the shortfall in meeting the mandated RN staffing ratio on those dates.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility continues to use recruiting services to fulfill staffing needs. Re-education will be provided to licensed nursing staff regarding staffing requirements and ratios, as well as education to ensure they do not leave the building before their relief has arrived. Facility continues to offer bonuses, use of agency, and mandate as needed to meet requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.