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 nursing care per resident per 24-hour period. This deficiency was identified through a review of nursing schedules over a 21-day period from January 23 to February 12, 2025. During this time, the facility consistently provided less than the required hours of care, with daily averages ranging from 2.98 to 3.14 hours per resident. The Administrator confirmed the shortfall in nursing care hours during an interview on February 14, 2025.
Plan Of Correction
1. The staffing minimum required nursing care hours ("HPPD") is unable to be corrected for the selected dates. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee will continue to work with Nursing Supervisors and the Staffing Coordinator to ensure the HPPD is at 3.20 or the state staffing minimum. Bonuses, position advertising, staffing flexibility, and agency use are measures used to secure staffing. Staffing will be based on current census and supervisors, or scheduler will contact other staff or agencies to cover call offs. 4. To monitor and maintain ongoing compliance, the DON/designee will audit schedules and HPPD weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.