Deficiency in Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days, June 29 and 30, 2024. On June 29, with a census of 94 residents, only 237.50 direct nursing staff hours were provided, resulting in 2.53 hours of care per resident. On June 30, with a census of 93 residents, 217.00 direct nursing staff hours were provided, equating to 2.33 hours of care per resident. These deficiencies were confirmed through a review of nursing time schedules, punch reports, and staff interviews, and were acknowledged by the Nursing Home Administrator during a review session on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.