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 for six specific days. The deficiency was identified through a review of nursing staffing documents and confirmed during a staff interview. On the dates in question, the facility's direct resident care hours per patient per day (PPD) were significantly below the required minimum, with the lowest being 0.30 PPD. The Nursing Home Administrator acknowledged the inability to provide all necessary staffing information to accurately calculate PPD for all days, confirming the shortfall in meeting the required care hours.
Plan Of Correction
The facility must maintain a minimum of 3.2 general nursing care hours for each 24-hour period. To ensure that this regulatory requirement is met, the following will be implemented: Education will be provided to the scheduler and Licensed Staff by the Director of Nursing/Designee on February 26, 2025, to ensure that they understand the regulatory requirement for general nursing care hours. Education was also provided to the Director of Nursing by the Administrator. The nursing schedule will be reviewed by the scheduler and Director of Nursing weekly to ensure that general nursing care hours are met prior to posting of the schedule. In the event of call-offs by staff, all other staff as well as those from our sister facilities will be contacted by the scheduler, Director of Nursing, or Licensed staff to cover any open shifts to ensure that general nursing care hours are met. Shift bonuses will also be offered as an incentive for shift pickups. The facility also utilizes a recruitment company to acquire qualified staff. An audit of the daily nursing schedules will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that a minimum of 3.20 general nursing care hours for each 24-hour period are met. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.