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 on two specific days. On December 6, 2024, the facility provided only 2.96 hours per patient day (PPD), and on December 11, 2024, it provided 3.16 PPD. This deficiency was identified through a review of the facility's nursing staffing documents covering the period from December 1, 2024, to December 14, 2024. The Nursing Home Administrator confirmed during a telephone interview that the facility did not meet the required minimum nursing care hours on these dates.
Plan Of Correction
The facility was unable to make corrective action for the minimum number of general nursing care hours for the identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 for PPD requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing Home Administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday - Friday to review nursing staffing throughout the day, the following day, and the weekend. In the event of vacancies, the Labor manager or Designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier to ensure shifts are filled and facility meets PPD requirements. Nursing Home Administrator or designee will audit daily staffing PPD along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.