Observations: Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one Registered Nurse (RN) per 250 residents during the night shift for 21 of 21 days (1/7/24 through 1/27/24).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following Registered Nurse staffing shortages:
On 1/7, 1/17, 1/18, 1/22, and 1/25/24, the census was 22, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
On 1/8, 1/19, 1/20, 1/21, 1/23, and 1/24/24, the census was 23, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
On 1/15, and 1/16/24, the census was 24, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
On 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/26, and 1/27/24, the census was 25, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
During an interview on 1/31/24, at 12:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one RN per 250 residents during the night shift on 21 of 21 days.
| | Plan of Correction - To be completed: 03/31/2024
1. Facility implemented the staffing requirements according to the P5540 regulation as of 3/31/2024.
2. Current Residents have the potential to be affected. The facility will hire an additional nurse for the night shift to implement the staffing ratios outlined in the P5540 regulation.
3. Administrator and or designee will educate Director of Nursing on the staffing ratio requirements that went into effect July 1, 2023. Harmony Physical Rehabilitation does meet the Hours Per Patient Day requirement; however, it is the ratio portion that was not met.
4. Director of Nursing, or designee will meet and audit the nursing schedule 5x per week for 2 weeks, weekly for 2 months and monthly for 2 months to ensure the facility adheres to the new ratio requirements. Corrected process will be reviewed quarterly by the quality improvement and quality assurance committee for further analysis and recommendation to ensure ongoing compliance.
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