RN Staffing Shortage During Evening Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during the evening shift on one of the days reviewed. Specifically, on January 18, 2025, the facility had a census of 107 residents but only 0.49 RNs were on duty, whereas 1.00 RN was required. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5540 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, DON/director of nursing and assistant director of nursing and charge nurses on the state required minimum staffing ratios for registered nurses. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for registered nurses are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for registered nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required registered nurse ratio and PPD, the interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Registered Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review registered nurse's ratios. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality performance and improvement process. 5. Dates when corrective action will be completed. March 3, 2025