Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum of one Registered Nurse (RN) per 250 residents during all shifts, effective July 1, 2023. This deficiency was identified during a review of nursing time schedules and staff interviews, which revealed that the facility did not meet the state minimum requirements for the night shift on eight out of 21 days. Specifically, on the nights of December 11, 12, 13, 18, 19, 20, 24, and 25, 2024, the facility had a census ranging from 81 to 88 residents but did not have any RNs present, despite the requirement for at least one RN. The Director of Nursing confirmed this failure during an interview conducted on January 17, 2025.
Plan Of Correction
1. The facility cannot correct that the RN staffing ratio was not met on 12/11/24, 12/12/24, 12/13/24, 12/18/24, 12/19/24, 12/20/24, 12/24/24, 12/25/24. There were no adverse effects to residents on the identified dates. 2. The facility will provide a minimum of one registered nurse per 250 residents. 3. Nursing Administration will be re-educated on staffing ratios by the Nursing Home Administrator/designee. Twice a day staffing meetings will be held to review the schedule with ratios. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility has started regular job fairs to increase staffing. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met and confirm that an RN is present on all shifts as required. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.