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 (PPD) for 10 out of 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and staff interviews. Specifically, on several days between December 29, 2024, and January 30, 2025, the facility's nursing care hours fell below the mandated threshold, with PPD ranging from 2.91 to 3.18. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing during an interview on January 30, 2025.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate PPD staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.