Observations:
Based on staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Registered Nurse during all shifts for seven of seven dates reviewed (July 12-18, 2024).
Findings Include:
A review of facility-provided staffing ratio information for July 12, 2024, on the day shift, revealed a census of 16 residents. Further review revealed a Registered Nurse (RN) ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift.
A review of facility-provided staffing ratio information for July 13, 2024, on the day shift, revealed a census of 16 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift.
A review of facility-provided staffing ratio information for July 14, 2024, on the day shift, revealed a census of 16 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift. Further review of the evening shift revealed an RN ratio of 4.25 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio of 8 hours for the facility census on the evening shift.
A review of facility-provided staffing ratio information for July 15, 2024, on the day shift and night shift, revealed a census of 16 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on those shifts.
A review of facility-provided staffing ratio information for July 16, 2024, on the day shift and night shift, revealed a census of 17 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on those shifts.
A review of facility-provided staffing ratio information for July 17, 2024, on the day shift, evening shift and night shift, revealed a census of 17 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on the day and night shift. Further review of the evening shift revealed an RN ratio of 4.75 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio of 8 hours for the facility census on the evening shift.
A review of facility-provided staffing ratio information for July 18, 2024, on the day shift, revealed a census of 17 residents. Further review revealed a RN ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift.
On July 24, 2024 at 5:33 PM, the Nursing Home Administrator was made aware of the above findings. No additional information was provided.
| | Plan of Correction - To be completed: 08/20/2024
A waiver for this regulation is being requested which will still allow for appropriate care of our resident population. This waiver continues to be pending. In the meantime, the facility will continue efforts to recruit additional Registered Nurses. Due to current court-ordered receivership, and lack of Registered Nurse applicants, the facility is hoping to staff RNs as follows: 1 RN 7a-3p, zero RN 3p-11p, and zero RN 11p-7a, with an RN within 30-minutes away on night shift.
If the waiver of this regulation is denied, the facility will ensure compliance following a review of the staffing schedule. Revisions will be made to such schedule to ensure compliance with regulation.
Additional agency staffing agreements will be obtained by 08/20/24 to help prepare for staffing emergencies.
Identification of Those Affected:
All residents have the potential to be affected by this deficient practice.
Systematic Change to Prevent Recurrence:
The facility has implemented a shift differential for shifts that have been difficult to recruit for. This shift differential pay was implemented on 07/28/24.
Indeed and job posting websites will be updated frequently to aid in promoting Registered Nurse applications.
RN Staffing will be reviewed daily M-F, during morning meeting, to include weekend review prior to such shifts. If RN staffing waiver is denied, facility will continue to recruit and will post for such shifts via agency as needed to meet State requirement.
The staffing coordinator, or designated employee, will notify the Administrator for occurrences when staffing levels may be at risk for noncompliance.
Monitoring to Ensure Compliance:
The staffing schedules will be reviewed at QAPI Meeting for 3 months or until substantial compliance is met.
8.15.24 Waiver was re-requested on 8/2/2024 to have an RN within a 30-minute drive from the facility for evening shift.
DON will continue to review and monitor staffing schedules on a daily basis to ensure appropriate coverage.
DON will review staffing schedule during daily stand-up meetings to ensure appropriateness in relation to compliance.
Agency staffing will be utilized when necessary.
New bonus structure will continue to encourage staff to pick up shifts.
DON will hold weekly clinical staffing meetings to assess for appropriate staffing levels and to ensure compliance is being achieved.
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