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 resident care per resident in each 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period from November 20 through December 10, 2024. On eight specific days within this period, the total nursing care hours fell below the required minimum. The specific days and the corresponding care hours per resident were as follows: November 23 (2.68 hours), November 27 (3.15 hours), November 28 (3.07 hours), November 29 (3.18 hours), November 30 (2.90 hours), December 1 (2.94 hours), December 7 (3.12 hours), and December 8 (3.11 hours). These findings indicate a consistent shortfall in meeting the mandated care hours for residents on these days.
Plan Of Correction
1) The facility cannot retroactively correct the staffing PPD issues. 2) The facility utilizes staffing agencies, bonuses for staff and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.