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 twelve out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. Specific dates were noted where the hours of direct resident care fell below the required minimum, with the lowest being 2.72 hours per patient per day. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified periods.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in PPD not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on Staffing ratios and PPD, call off policies, and attendance expectations to be completed by DON/designee and human resources. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Staffing will be monitored daily by DON/Designee as well as NHA at end of stand up meeting. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/DON. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Staffing audits to be completed at monthly QAPI meeting. Audits will consist of PPD and deployment zones for the day which may indicate patterns for intervention. This will include unit, days of any missed PPD if any, and corrective actions pursued or utilized at the time of the event. QAPI has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility. Facility continues to investigate local education centers and community events for recruitment opportunities.