RN Staffing Deficiency
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one registered nurse (RN) per 250 residents during all shifts. This deficiency was identified through a review of nursing schedules and staff interviews, revealing that on four separate days, the facility did not have the required RN coverage. Specifically, on 09/02/2024, with a census of 192 residents, only 0.79 RN was available during the day shift. On 05/23/2024, with a census of 198 residents, the facility provided 0.99 RN during the evening shift and 0.96 RN during the night shift. Additionally, on 05/24/2024, with a census of 195 residents, only 0.95 RN was available during the night shift. In all instances, there were no additional higher-level staff available to compensate for the RN shortfall.
Plan Of Correction
There were no adverse effects to the residents in the center as a result of the Registered Nurse ratios for the night shift staffing during the months of May, September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed nurse ratio of one licensed nurse per 250 residents on each shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.