Observations
Based on the review of staff schedules, payroll records and interviews with staff; the facility failed to comply with the client/staff ratios during primary care hours.
The findings included:
A review of staffing schedules, a review of payroll records and staff interviews were conducted during the on-site incident investigation on October 1, 2014. Primary care hours are 24/7 for the detoxification level of care and require one FTE primary care staff person for every seven clients during all shifts. The facility's documentation of client census information identified that fourteen clients were in the detoxification unit on the morning of August 26, 2014. There was only one licensed nurse scheduled and working between the hours of 2:30am - 6:45am on August 26, 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Regarding 704.12 Citation from 10/1/14 Survey
1. The weekly shift schedule will be reviewed daily by the Nurse Manager or her second to assure adequate staff coverage is in place.
2. In the event that there is an emergent problem with having the full coverage, one FTE-primary care staff person available for every seven patients during primary care hours, the Nurse Manager or her designate are to be notified immediately. In the event that there is any problem with coverage that the Nurse Manager can not rectify herself the Executive Director or Clinical Director is to be immediately notified to resolve the problem.
3. The Nurse Manager is to maintain a ready pool of Per Diem, fully licensed Nurses that have been trained so as to provide coverage in the event of a shift deficit. The Nurse Manager will maintain a ready resource off the personnel's phone numbers for ease of access
Compliance with the aforementioned plan of correction will be monitored at monthly supervisor's meeting. Person responsible for implementation and correction of this deficiency is the Executive Director.
|