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 resident care per resident in a 24-hour period for twelve out of fourteen days reviewed. The deficiency was identified through a review of nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. On specific dates, the facility's direct resident care hours per patient per day (PPD) fell below the required minimum, with recorded PPDs ranging from 2.92 to 3.10. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified period.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing PPD of 3.2 for 11/24/24, 11/25/24, 11/26/24, 11/27/24, 11/29/24, 11/30/24, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25 and 1/7/25. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing to PPD. 3. Nursing home administrator/designee will schedule staff to meet state PPD of 3.2. Call outs will be monitored by nursing home administrator/Director of nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonuses to increase applicants as well as pick up bonuses to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of the minimum PPD of 3.2. 5. Nursing home administrator and/or designee will monitor staffing PPD weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.