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 ratio for 21 of 21 days reviewed.
Findings include:
Review of nursing schedules from January 1 through 14, 2024, and February 1 through 7, 2024, revealed the following:
The facility failed to meet the minimum RN to resident ratio of one RN to 250 residents on the night (11:00 p.m. through 7:00 a.m.) shift from January 1 through 14, 2024, and February 1 through 7, 2024.
| | Plan of Correction - To be completed: 04/23/2024
1- The facility is unable to correct, and it is impractical to conduct a baseline audit, of actual staffing ratios taking place before this proposed plan of correction.
2- Nurse management will be educated as to the clarified PA Code 211.12 Nursing Services as it relates to minimum nurse staffing levels. These newly understood requirements will be introduced to the facilities nurse staffing pattern.
3- An audit of nurse staffing patterns and future schedules will be conducted twice a week for 3 weeks by the administrator for accuracy and effectiveness.
4- Results of these audits will be submitted to the Quality Assurance and Performance Improvement Committee for evaluation, and to determine whether a additional measure to the prescribed plan of correction is warranted for improved results.
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