Failure to Meet RN Staffing Ratios on Night Shifts
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 on three occasions. Specifically, on December 26, 2024, December 31, 2024, and January 2, 2025, the facility had no RNs on duty during the night shift, despite having a census of 32 and 33 residents, respectively. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Director of Nursing on January 16, 2025. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. The facility is unable to retroactively provide minimum registered nurse ratio for cited dates. 2. A facility wide audit was completed to ensure ratios were met. Recruitment increased, RN sign on bonuses, and wages are competitive with surrounding areas. 3. The DON was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting RNs. The DON will review census and schedule daily to ensure adequate staffing of RN's each day. 4. The DON or designee will conduct an audit of the registered nurse ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.