Failure to Maintain Required RN Staffing Levels
Penalty
Summary
Crest Haven Nursing and Rehabilitation Center failed to ensure that a registered professional nurse (RN) was on duty at all times, as required for facilities with more than 150 licensed beds. During a review of staffing records for multiple weeks, it was found that the facility did not have an RN on duty for a significant number of shifts—147 out of 231 shifts reviewed. Specific weekly breakdowns showed that, in several weeks, the facility lacked RN coverage for 10 to 14 out of 21 shifts per week. The Licensed Nursing Home Administrator (LNHA) confirmed the facility had 180 licensed beds and a resident census of 74 at the time of the survey. The facility's own policy stated that a RN should oversee total nursing activities on each tour of duty every day of the week. Interviews with facility leadership revealed a misunderstanding of the regulatory requirement, with the LNHA stating that an RN was only required for eight hours in a 24-hour period for facilities with more than 120 beds, which does not align with the cited regulation. The deficiency was identified through both interviews and review of the facility's nurse staffing reports (AAS-11), which documented the lack of RN coverage during the reviewed periods.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility actively seeks to hire Registered Nurses (RNs), ensuring that all shifts are scheduled to comply with the requirement. The facility has documented evidence to reflect recruitment and retention efforts in its relentless attempts to comply with the staffing ratios. All residents have the potential to be affected by this deficient practice. Staffings Coordinator and Director of Nursing were educated by the Administrator on current staffing regulations and RN coverage for buildings licensed for 150 or more beds. Recruitment and retention efforts include: a. Daily staffing meetings and weekly Regional Labor Management reviews b. Training mentor program to support retention c. Employee Enrichment committee d. Collaboration with nursing schools The DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for continued review and recommendations until substantial compliance is maintained.