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 nursing care per resident per day on 15 out of 19 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing ratios include July 1-5, 2024; September 28-30, 2024; October 1-4, 2024; and February 7-9, 2025. On these dates, the facility's census ranged from 88 to 95 residents, and the direct nursing care hours provided per resident varied from 2.65 to 3.18 hours, consistently falling short of the mandated 3.2 hours on most days. The Nursing Home Administrator confirmed the shortfall in staffing ratios during a review of staffing calculations, nursing staff schedules, and staff punch reports on February 11, 2024. The deficiency was evident as the facility consistently failed to provide the required level of direct nursing care, impacting the quality of care provided to the residents. The report does not mention any corrective actions or plans to address this deficiency, focusing solely on the failure to meet the required staffing levels on the specified dates.
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 for 4 weeks, then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.