Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed registered nurse (RN) to resident ratios for 13 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from February 18, 2024 through February 24, 2024, April 7, 2024 through April 13, 2024, and May 16, 2024 through May 22, 2024, revealed the following:
The facility failed to meet the minimum RN to resident ratio of one RN for 250 residents in addition to the director of nursing services on day (7:00 a.m. to 3:00 p.m) shift on February 19, 20, 21, 22, 23, and 24, 2024, and April 7, 8, 9, 10, 11, and 12, 2024 .
The facility failed to meet the minimum RN to resident ratio of one RN 250 residents on evening (3:00 p.m. to 11:00 p.m.) shift on February 19, 2024, April 7, 2024, and May 18, 2024.
| | Plan of Correction - To be completed: 06/25/2024
The facility will have a Registered Nurse scheduled, that does not include the Director of Nursing, on the 7-3 and 3-11 shift. An RN will be available on the 11-7 shift as required under staffing regulations and as determined by the resident census.
Staff are currently being educated as to the Deficiency and the requirements.
This will be accomplished by the redeployment of a currently employed full-time Registered Nurse (not being the Director of Nursing) to the hours of 7:00 am to 3:00 pm. Additionally, the facility has hired a Weekend RN Supervisor effective June 5, 2024 to fill the Saturday and Sunday 7:00 am to 7:00 pm. Shift.
Evidence of compliance: The Nursing Department Scheduler is responsible for the creation and maintaining of the schedule under the direct supervision of the Director of Nursing.
The Administrator and Director of Nursing will perform an audit of the forthcoming week's schedule monitoring the intended RN staffing on each shift.
The facility will allege compliance effective June 25, 2024.
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