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 24 shifts out of 54 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum Registered nurse (RN) staff of 1:250 on the day, evening, and night shift based on the facility's census.
November 25, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 86. November 25, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86. November 26, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86. November 27, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. November 28, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86. November 29, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. November 30, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 1, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87. December 1, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 2, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87. December 3, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 4, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87. December 4, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 5, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 6, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 7, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87. December 8, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 86. December 8, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84. December 9, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 84. December 9, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 84. December 9, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84. December 10, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 84. December 10, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84. December 11, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84.
An interview with the Nursing Home Administrator on December 13, 2023, at approximately 2:50 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.
| | Plan of Correction - To be completed: 01/24/2024
Facility cannot retroactively correct this deficiency.
Per the Department of Health regulation 211.12 (nursing services) "Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts" is required. On the following dates listed in the DOH 2567; November 25-30, 2023, and December 1-11, 2023 the facility did in fact have 1 RN on duty during all shifts.
Recruitment of nursing staff will continue via facility website, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.
Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff.
The Director of Nursing/designee will review the ratio daily for compliance. All efforts will be made to meet RN staffing ratios. If a call off occurs all efforts will be made to fill that position.
The Director of Nursing/designee will audit the RN ratio 1x/week for 4 weeks then monthly for 2 months.
Staffing will be following the revised ratio methodology beginning January 1, 2024
Results will be presented to QA committee for review and recommendation.
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