Observations
Based on the review of staff schedules and an interview with the General Manager and the President of the corporation, the facility failed to comply with the client/staff ratios on two days of a ten month time frame.
The findings include:
Staffing schedules between November 1, 2013 and August 30, 2014 were reviewed on September 11, 2014.
Primary hours are 24/7 for detoxification level of care and require one FTE primary care staff person for every seven clients during all shifts. The facility failed to ensure that a nurse was scheduled for the 11:30 PM to 7:30 AM shift on November 6, 2013 and November 15, 2013 when there was a client in detox.
|
Plan of Correction
Beginning in October,1 2014 the nursing schedule will be updated to include the number of residents in detox on each day of the month. On the days that there is one (or more) resident(s) in detox, a third shift nurse will be scheduled so that all shifts are covered. Nursing notes will clearly reflect the status of residents, indicating each day that is spent in detox with a special note when the resident is being transferred from detox into rehab. The total number of residents in detox each day will be recorded on the nursing schedule and the nurse on duty during first shift will inform the supervisor how many residents are in detox on any given day. The supervisor will ensure that there is third shift coverage when there is a resident in detox. The monthly schedule will be reviewed by the compliance officer to ensure that the procedure is being properly followed. |