Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required Registered Nurse (RN) to resident ratio of 1 RN per 250 residents during the night shift for seven consecutive nights. Specifically, from January 20 to January 26, 2025, the facility did not have any RNs on duty during the night shift, despite having a census ranging from 32 to 34 residents, which necessitated at least one RN per shift. The absence of RNs on these nights was confirmed by a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulation effective July 1, 2023.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Registered Nurses hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Registered Nurse ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Registered Nurses for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.