Failure to Maintain Required ADON Staffing
Summary
The facility failed to ensure compliance with the mandatory nurse staffing requirement by not having an Assistant Director of Nursing (ADON) who is a registered professional nurse (RN) in place, as required for facilities with 150 licensed beds or more. During the entrance conference, the Licensed Nursing Home Administrator (LNHA) confirmed that the facility was licensed for 180 beds and had a current resident census of 74. Upon further inquiry, the LNHA acknowledged that an ADON was required due to the facility's bed count, but stated that the previous ADON had resigned and the position was currently vacant. This deficiency was identified through interviews and direct confirmation from facility leadership.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility has designated an interim RN ADON while still actively seeking to hire a Registered Nurse (RN) Assistant Director of Nursing (ADON). All residents have the potential to be affected. Staffing Coordinator and Director of Nursing were educated by the Administrator on current staffing regulation and RN, ADON coverage for buildings licensed for 150 or more beds. DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months to ensure that an ADON is staffed. All findings from the audits will be reported, reviewed by the DON or designee, and submitted to the monthly Quality Assurance and Performance Improvement Committee (QAPI) for three (3) months in order to determine if further interventions are needed.
Penalty
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