Deficiency in Meeting 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 over a 24-hour period. This deficiency was identified during a review of the facility's nursing staffing documents and confirmed through staff interviews. Specifically, on three separate days, the facility's nursing care hours fell below the required minimum: 2.84 hours on one day, 2.98 hours on another, and 3.19 hours on a third day. The Nursing Home Administrator acknowledged the shortfall in meeting the mandated nursing care hours on these dates.
Plan Of Correction
The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to at least meet the required 3.2 minimum general nursing care Per Patient Day hour requirement. The Director of Nursing or designee will provide re-education on minimum general nursing care staffing hours to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate general nursing care staffing hours. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets minimum general nursing care staffing PPD. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of general nursing care staff hours have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, and mandating when needed. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.