Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for 7 out of 10 days reviewed. Specifically, from January 6, 2025, through January 16, 2025, the facility's nursing staffing data showed that the provided hours per patient day (PPD) fell below the mandated threshold on several occasions. On January 7, 2025, the PPD was 3.05; on January 11, 2025, it was 3.17; on January 12, 2025, it was 2.95; on January 13, 2025, it was 3.09; on January 14, 2025, it was 3.12; on January 15, 2025, it was 2.95; and on January 16, 2025, it was 2.99. These deficiencies were identified during a review of the facility's staffing documentation, indicating a consistent shortfall in meeting the state's minimum staffing requirements.
Plan Of Correction
1. The PPD cannot be corrected as this it is an event in the past. 2. The PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility continues to develop a recruitment plan to attract nursing staff. The facility scheduler, DON, HR, and NHA will meet daily to review compliance with ratios. In the event of call-offs, every effort to contact regular full-time and part-time staff as well as PRN and agency staff will be made by facility personnel. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. Recruiters will seek out applicants sourcing Indeed and Apploi for staff. The facility will offer 12-hour shifts to enhance employment offers. 4. PPD will be monitored daily by the scheduler and DON/designee. Facility compliance with PPD will be monitored through the monthly QAPI process. Ratios will be monitored daily by the scheduler and/or DON/designee. Audits of PPD will be completed by the DON/designee daily for 4 weeks, then 3 times per week for two months or until substantial compliance is achieved. The results of the audits will be reviewed at the monthly QA meeting.