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 six specific days within the review period from December 10, 2024, to December 30, 2024. The nursing staffing documents revealed that on December 22, 23, 24, 25, 27, and 29, 2024, the hours of direct resident care fell below the required minimum, with the lowest being 2.50 hours on December 25, 2024. This deficiency was confirmed during an interview with the Assistant Director of Nursing on January 3, 2025, who acknowledged that the facility did not meet the required care hours on the specified dates.
Plan Of Correction
1. Additional Staffing Agencies have been added to the facility to provide additional nursing staff to meet the state minimum requirement of 3.20 hours of direct resident care for each resident in a 24-hour period. Education will be provided to the Director of Nursing, Asst. Director of Nursing and the Scheduler no later than 1/24/2025 to ensure that they understand the regulatory staffing requirement. 2. The nursing schedule consisting of all three (3) disciplines (RN/LPN/CNA) will be reviewed by the Scheduler, Director of Nursing and/or Asst. Director of Nursing to ensure that the requirement of 3.20 direct nursing care hours is met prior to posting of the schedule. In the event of call-offs by staff, all facility nursing staff and/or agency staff will be contacted to cover any open shifts to ensure the 3.20 direct nursing care ratio is met. The facility continues to utilize job boards and various recruiting venues to attract, interview, recruit, and hire new staff. The facility conducts Recruitment and Retention Committee meetings weekly and has adopted a monthly rewards and recognition programs to retain current staff. The facility will conduct Staffing Meetings and Quality Calls with upper management five (5) days per week to ensure compliance. 3. An audit will be conducted by the Director of Nursing and/or designee, daily for two (2) weeks, three (3) times per week for one (1) week, then weekly ongoing to ensure that 3.20 hours of direct nursing care ratio is met for the 24-hour period. The audit will be monitored by the Director of Nursing and/or Assistant Director of Nursing. 4. The Director of Nursing will submit all Staffing Audits will be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee at the monthly meeting for review and recommendation.