Observations:
Based on review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Registered Nurse (RN) per 250 residents on all shifts for two of 21 days reviewed (4/13/24 and 4/14/24).
Findings include:
Review of facility staffing ratio information from 1/14/24 through 1/20/24, 2/05/24 through 2/11/24, and 4/11/24 through 4/17/24, revealed the following RN staffing shortages for the daylight shift:
4/13/24census of 66 residents, 0.93 RNs scheduled and 1.0 was required.
Review of facility staffing ratio information from 1/24/24 through 1/20/24, 2/05/24 through 2/11/24, and 4/11/24 through 04/17/24, revealed the following RN staffing shortages for the evening shift:
04/14/24census of 65 residents, 0.61 RNs scheduled and 1.0 was required.
During an interview on 4/17/24, at approximately 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the required ratios of one RN per 250 residents on all shifts on the dates listed above.
| | Plan of Correction - To be completed: 06/18/2024
There were no residents found to have been affected by deficient practice on 4/13/24 or 4/14/24. The RN was in the building, however had to be utilized as an LPN to cover the LPN ratio hours, as the LPN was needed to cover for nurse aide hours. No adverse events took place and all resident needs were met.
To ensure the deficient practice does not recur, nurses will be reeducated at their next monthly meeting on 5/14 on the staffing regulation requirements to ensure they understand the importance of scheduling and what staffing minimums and ratios the facility must meet daily per census. Facility will continue all recruitment strategies: advertising on social media, newspaper, website, digital signage in front of property, staff newsletter, resident/family newsletter, non-profit partnership job board, eNewsletter, radio ads, job fairs, Carelistings.com and Career Link. Current staff are offered a referral bonus if their referral is hired and maintain employment for a period of time. Human Resources and the Administrative Team routinely compare salaries for nursing positions listed to remain competitive. Staffing agencies are utilized as needed to meet schedule requirements or fill in for a call off. Human Resources and DON respond to applications right away and interviews are set up at all hours to accommodate varied needs of the applicant. Facility also sends qualified personal care aides from its personal care building to CNA classes in an attempt to continue growth of certified nurse aides available. Facility is a clinical host site for CNA classes, and welcomes students throughout the year and actively works to recruit from these clinical rotations.
DON will complete schedule based on projected census. DON will monitor resident census and staff schedule daily and use Staffing Hours Calculator tool to ensure facility is in compliance. If facility will not be in compliance DON will call all staff to work as needed to meet staffing minimum. If no staff are available agency will be contacted to fill the need. Administrator will review and initial staff schedule each Tuesday for compliance of upcoming week (Tuesday through Monday). Administrator will review and initial staff schedule at the end of the week worked to ensure it was maintained. This will continue for three months.
Plan of correction will be reviewed at monthly QAPI meetings for the next three months.
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