RN Staffing Deficiency
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during all shifts. This deficiency was observed over a 14-day period from December 30, 2024, to January 12, 2025. During this time, the facility did not meet the required RN staffing levels for the day shift on 12 out of 14 days, for the evening shift on 13 out of 14 days, and for the overnight shift on 13 out of 14 days. Specific instances included days where no RNs were present despite a resident census that necessitated at least one RN, such as on January 1, 2025, when the census was 102 residents, but no RNs were on duty. The deficiency was confirmed through a review of the facility's nursing staffing documents and a telephone interview with the Nursing Home Administrator. The administrator acknowledged the failure to meet the minimum RN staffing ratios on the specified days and shifts. This lack of adequate RN staffing could potentially impact the quality of care provided to the residents, although the report does not detail any specific adverse outcomes resulting from this deficiency.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure future ratios do not fall below 1 RN per 250 residents on all shifts. The DON or designee will proactively preview daily ratios to ensure adequate staff coverage. The scheduler or designee will review projected staffing levels with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to ensure that any foreseeable issues with regard to adequate ratios to ensure regulation is met. The scheduler or designee will review the working schedules with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to determine what changes need to be made to ensure staffing levels are met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. Agency RN usage will be utilized as needed. Scheduler and nursing supervisors have been educated on required staffing ratios. Results of audits will be reviewed at the Quality Assurance committee. 03/05/2025 Date of compliance.