Deficiency in Meeting 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 day for 20 out of 21 days reviewed. The review of nursing schedules from December 9 through December 29, 2024, revealed that the facility consistently fell short of the required care hours, with the lowest being 2.08 hours per resident on December 25, 2024. The Director of Nursing confirmed during an interview that the facility did not meet the minimum required nursing care hours on the identified days.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Re-introduction of a Nurse Aide Training program is scheduled with classes to train new nurse aides. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 03/05/2025.