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 11 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 2, July 4, July 5, July 6, July 7, October 28, October 31, November 1, November 2, November 3, and December 8, 2024. On these dates, the facility's census ranged from 127 to 135 residents, and the direct nursing care hours provided per resident varied from 2.70 to 3.14 hours, all falling short of the mandated 3.20 hours. The deficiency was confirmed during a review with the Scheduler, Employee E7, on December 12, 2024. The review of staffing calculations, nursing staff schedules, and staff punch reports corroborated the finding that the facility did not meet the required staffing minimum on the specified dates. This failure to provide adequate nursing care hours is a direct violation of the regulation effective July 1, 2024, which mandates a minimum of 3.20 hours of direct nursing care per resident per day.
Plan Of Correction
Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI. Scheduler and Nursing Leadership were educated as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.