Insufficient Nursing Staff Leads to Care Deficiency
Penalty
Summary
Hanover Hall for Nursing and Rehabilitation was found to be non-compliant with the requirement for sufficient nursing staff as per 42 CFR Part 483.35(a)(1)(2). The facility failed to provide adequate nursing services to ensure the safety and well-being of its residents, specifically for one resident. The deficiency was identified through document reviews, policy reviews, and interviews with residents and staff. The facility's policy on comprehensive person-centered care plans, which mandates the development and implementation of care plans to meet residents' needs, was not adhered to. Additionally, the facility's policy on resident rights, which includes treating residents with dignity and responding to grievances, was not fully implemented. The deficiency was highlighted by the case of a resident who was scheduled to receive showers twice a week during the day shift. However, a grievance was filed by the resident's daughter, indicating that the resident was not receiving the scheduled showers. Documentation revealed that the resident only received bed baths on two occasions in January 2025, with no record of showers or bed baths on two other scheduled dates. An interview with the DON and a nurse aide confirmed that the facility was short-staffed on those dates, preventing the provision of care as per the resident's person-centered plan.
Plan Of Correction
1. R4 did receive a shower on 1/24, 1/31, 2/4, and 2/7, and a bed bath on 1/27. There were no adverse effects from not receiving a shower on 1/17 and 1/21; he did receive AM and PM personal hygiene care on these days. 2. The facility will audit the last two weeks of shower schedules to ensure residents are receiving showers/bed baths as scheduled. 3. Re-education will be provided to nursing staff regarding documentation with bathing, as well as offering showers the next shift or day as necessary. Re-education will be provided on staffing ratios and minimum PPD. 4. DON/designee will conduct audits of 10 residents/week x4 weeks, and then 10 monthly x2 months to ensure residents are receiving showers/or bed baths as scheduled. Staffing levels will be monitored daily to ensure minimum requirements are being met. Results will be reviewed at QAPI to ensure compliance and ongoing quality care.