Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct nursing care per resident per day on 16 out of 21 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing levels include July 14, 15, 16, 17, 18, and 20, 2024; September 3, 4, and 7, 2024; and January 17, 18, 19, 20, 21, 22, and 23, 2025. On these dates, the facility's census ranged from 112 to 123 residents, and the direct nursing care hours provided per resident varied from 2.67 to 3.19 hours, falling short of the mandated 3.20 hours. The Nursing Home Administrator confirmed the shortfall in staffing during a review of the staffing calculations, nursing staff schedules, and staff punch reports on January 24, 2025. The deficiency was consistently observed across multiple months, indicating a systemic issue in maintaining adequate staffing levels to meet the regulatory requirements. The report does not provide any information on corrective actions or plans to address this deficiency.
Plan Of Correction
No residents were negatively impacted by not meeting 3.20 PPD. The facility completed an audit of HPPD for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the required HPPD. The Administrator has reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit centers HPPD 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.