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 four out of seven days reviewed. Specifically, on January 5, 2025, the facility provided only 2.90 hours of direct care per resident, 2.52 hours on January 6, 2025, 3.05 hours on January 10, 2025, and 2.89 hours on January 11, 2025. This deficiency was confirmed during an interview with the Nursing Home Administrator, who attributed the shortfall to staff call-offs related to illnesses and adverse weather conditions.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. Residents will continue to receive care in accordance with their plan of care and attending physician orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily for 4 weeks, then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.