Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on 14 out of 21 days. This deficiency was identified through a review of nursing time schedules and staff interviews. Specific dates where the facility did not meet the required nursing hours include 11/08/24, 11/09/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 01/26/25, 01/29/25, 01/30/25, 01/31/25, and 02/01/25. The facility's census on these dates ranged from 102 to 107 residents, with the provided nursing hours per resident per day (PPD) falling short of the required 3.2 hours, with PPDs as low as 2.19 on some days. The Nursing Home Administrator confirmed these findings during an interview on 1/29/25.
Plan Of Correction
The facility will ensure that the state minimum staffing requirement of 3.2 PPD is met in order to ensure the health and safety of all residents. The facility is unable to retroactively correct the concern of the minimum staffing requirement not being met on dates: 11/08, 11/09, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 1/26, 1/29, 1/30, 1/31, and 2/1. The facility will continue to ensure all efforts are exhausted to maintain the minimum staffing requirement of 3.2 PPD on a daily basis to ensure the health and safety of all residents. The facility will continue to acquire agency staff as needed to meet the 3.2 PPD requirement. Recruitment efforts are underway, and a plan is in place. Bonuses will be offered to all staff to pick up shifts. Facility admissions will be limited if the staffing requirement cannot be met. The Regional Clinical Consultant will re-educate the Administrator, Director of Nursing, and staffing coordinator on the "Nursing Department Staff" policy, which outlines the minimum staffing requirements and steps that are to be taken in order to ensure staffing requirements are met to ensure the health and safety of all residents. The Administrator or designee will audit staffing levels five times a week for four weeks and then monthly for three months to ensure the minimum staffing requirement of 3.2 PPD is met to ensure the health and safety of all residents. Findings of audits will be reported to the monthly Quality Assurance & Performance Improvement (QAPI) for review, recommendations, and frequency of audits.