Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. On January 31, 2025, the facility provided only 3.12 hours of direct care per resident, and on February 1, 2025, the care hours further decreased to 2.90 per resident. This deficiency was confirmed through a review of the facility's staffing levels and an interview with the Director of Nursing on February 13, 2025, who acknowledged the shortfall in meeting the required nursing care hours.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.