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 nursing care per resident per day. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. On six out of seven days reviewed, the facility did not provide the required hours of care. Specifically, on November 29, 2024, with a census of 209 residents, only 567.25 hours of direct nursing care were provided, equating to 2.71 hours per resident. Similar shortfalls were noted on subsequent days, with the facility consistently providing less than the mandated 3.2 hours of care per resident. The deficiency was further evidenced by specific data from each day reviewed. For instance, on December 1, 2024, with a census of 210 residents, only 527.25 hours of care were provided, resulting in 2.51 hours per resident. On December 4, 2024, with a census of 208 residents, the facility provided 537.75 hours of care, equating to 2.59 hours per resident. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to comply with the required staffing levels.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure the state minimum requirement of 3.2 hours of direct resident care is met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state direct resident care hours requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.