Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) during the overnight shift on January 29, 2025. The facility census required 35.06 hours of LPN care, but only 34.00 hours were provided. This discrepancy was confirmed by the Director of Nursing during a review of staffing calculations, nursing staff schedules, and punch reports on January 31, 2025. Additionally, the facility did not provide the mandated minimum of 3.20 hours of direct nursing care per resident on five out of fourteen days reviewed. On December 29, 2024, and January 24, 25, 26, and 27, 2025, the facility's direct nursing care hours per resident fell short, with the lowest being 2.37 hours on January 25, 2025. These findings were also confirmed by the Director of Nursing, indicating a consistent failure to meet the required staffing levels and direct care hours for residents.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the state required PPD of 3.2 per patient day. The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD is being met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.