Failure to Meet RN Staffing Ratios on Overnight Shifts
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios of one Registered Nurse (RN) per 250 residents during the overnight shift for five consecutive nights from March 6, 2025, to March 10, 2025. A review of the nursing schedules revealed that on these dates, the facility provided significantly fewer RN service hours than the required 8 hours per shift, despite having a resident census ranging from 48 to 50. Specifically, the facility provided only 1.59 hours on March 6, 0.83 hours on March 7, 0.75 hours on March 8, 1.13 hours on March 9, and 0.90 hours on March 10. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the RN ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on RN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to add an LPN in place of the RN due to the waiver related to our building size to ensure ratios are met. 4. DON/designee will conduct daily audits to verify nursing ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.