Deficiency in 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. This deficiency was identified during a review of nursing schedules over a 14-day period from December 22, 2024, to January 4, 2025. Specifically, on December 25, 2024, the facility provided only 3.14 hours of care per resident, and on January 1, 2025, only 3.10 hours per resident. The Administrator confirmed during an interview that the facility did not meet the required nursing care hours on these days.
Plan Of Correction
Administrator, Assistant Administrator and Nursing Administration including Nursing Supervisors will review staffing ratios and PPD requirements. The DON or designee will re-educate the Nursing Supervisors and nursing schedulers on the ratio and PPD requirements. A daily audit of nursing hours/ratios will be completed by the DON or designee for 7 days, then weekly for three weeks and then every other week for 4 weeks. Results of the audits will be reported to the QAPI committee.