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 resident care per resident in a 24-hour period on six specific days within a two-week period. The review of nursing staffing documents revealed that the facility provided less than the required hours of care on January 1st, 3rd, 4th, 5th, 6th, and 8th of 2025, with the lowest being 2.64 hours per patient per day on January 5th. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview, acknowledging the shortfall in meeting the mandated care hours on the specified dates.
Plan Of Correction
The facility acknowledges that, as of 1/21/2025, the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for six of 14 days reviewed (1/01/25, 1/03/25, 1/04/25, 1/05/25, 1/06/25 and 1/08/25). The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval. Instruction has been provided to the DON, Scheduler, and Nursing Supervisors to ensure that they know how to achieve a 3.2 hours PPD in creating schedules and deal with call-offs. Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime. The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to ensure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.