Deficiency in 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 and staff interviews, which revealed that the facility did not provide the required hours of care on 16 out of 21 days reviewed during September and December 2024. Specific instances of non-compliance included days where the facility census ranged from 182 to 194 residents, yet the hours of direct nursing care provided per resident fell short, with figures as low as 2.61 hours on certain days. The deficiency was consistent across multiple days, indicating a systemic issue in staffing or scheduling that prevented the facility from meeting the mandated care hours. The shortfall in nursing care hours was documented on specific dates, such as September 1st through 7th and December 11th through 17th, where the care hours ranged from 2.61 to 3.12, all below the required 3.2 hours. This failure to provide adequate nursing care hours could potentially impact the quality of care and well-being of the residents, although the report does not specify any direct consequences or risks that arose from this deficiency.
Plan Of Correction
There were no adverse effects to the residents in the center as a result of less than 3.2 direct care for each resident were provided during the months of September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites, and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors, and Director of Nursing were re-educated on maintaining a minimum of 3.2 direct resident care for each resident. Administrator or designee to complete random audits weekly for 6 weeks for licensed nurse ratios for all shifts to ensure 3.2 PPD is maintained. Findings will be reviewed in QAPI. Findings will be reviewed in QAPI.