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 in a 24-hour period on February 8, 2025. A review of staffing and resident census data for the week of February 2 - 8, 2025, showed that on February 8, the facility provided only 3.02 hours of direct care per resident. During an interview on February 10, 2025, the Nursing Home Administrator and Director of Nursing acknowledged the shortfall and attributed it to staff call outs and the inability to fill all open slots, which resulted in the facility being understaffed on that day.
Plan Of Correction
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the minimum of 3.2 hours of direct resident care for each resident and replacement of staff if indicated. 3. A staffing direct resident care document will be completed daily by the scheduler and reviewed at morning meetings. The direct resident care document will be updated with any changes in the schedule and reviewed with the DON/Admin Nurse to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. An audit of the direct resident care document against the deployment sheet will be completed daily for 1 week, weekly for 2 weeks and then biweekly X 2 weeks. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.