Observations:
Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum registered nurse staff to resident ratio was provided on each shift for 13 shifts out of 42 shifts reviewed.
Findings include:
A review of the facility's staffing records revealed that on the following dates the facility failed to provide minimum registered nurse (RN) staff of 1:250 and based on the facility census of 59 or less failed to substitute a licensed practical nurse for a registered nurse on the night (overnight) shift if an RN is on call and located within a 30-minute drive of the facility.
January 24, 2024 - 0 RN on night shift versus, the required 1 for a census of 42. January 25, 2024 - 0 RN on night shift versus, the required 1 for a census of 43. January 26, 2024 - 0 RN on night shift versus, the required 1 for a census of 42. January 27, 2024 - 0 RN on night shift versus, the required 1 for a census of 40. January 28, 2024 - 0 RN on night shift versus, the required 1 for a census of 40. January 30, 2024 - 0 RN on night shift versus, the required 1 for a census of 41. January 31, 2024 - 0 RN on night shift versus, the required 1 for a census of 42. February 1, 2024, - 0 RN on night shift versus, the required 1 for a census of 42. February 2, 2024, - 0 RN on night shift versus, the required 1 for a census of 40. February 3, 2024, - 0 RN on night shift versus, the required 1 for a census of 40. February 4, 2024, - 0 RN on night shift versus, the required 1 for a census of 40. February 5, 2024, - 0 RN on night shift versus, the required 1 for a census of 41. February 6, 2024, - 0 RN on night shift versus, the required 1 for a census of 41.
An interview with the Director of Nursing (DON) on February 7, 2024, at approximately 11:00 AM, confirmed that the facility had not met the required RN to resident ratios on the above shifts.
| | Plan of Correction - To be completed: 03/01/2024
The facility cannot retroactively correct past staffing. No issues were noted with residents. The facility cannot retroactively correct past staffing issues. Moving forward the facility will continue to make good faith effort utilizing internal resources in the event of unforeseen staffing requirement deficits to make a good faith effort to ensure the staffing mandate is followed. To prevent this from reoccurring the RVPO/designee will reeducate the NHA/DON on updated staffing regulations regarding staffing ratios and ensure a staffing meeting is held between the Don and NHA 5 days a week to ensure staffing ratios are met. To monitor and maintain ongoing compliance the NHA/designee will audit deployment sheets to ensure the facility is staffed in accordance with the mandated requirements 5X's weekly X4, then weekly X2 months. The results of the audits will be forwarded to facility QAPI committee for further review and recommendations.
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