Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum general nursing care hours for residents on two specific days. On January 18, 2025, the facility provided 3.13 direct care nursing hours per resident, and on January 22, 2025, it provided 3.07 direct care nursing hours per resident. These figures were below the mandated minimum of 3.20 hours of general nursing care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025.
Plan Of Correction
1. The facility failed to maintain a minimum of 3.2 hours of direct resident care for each resident on multiple days and shifts. 2. Facility will need to maintain a PPD of 3.2 hours. Calculation of the PPD will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisor will be educated on the daily PPD. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.