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 for six out of seven days reviewed. Specifically, on December 14, 15, 16, 17, 19, and 20, 2024, the facility provided less than the required hours, with the lowest being 2.14 hours on December 10. This deficiency was confirmed during an electronic communication with the Nursing Home Administrator on December 24, 2024, at 9:00 AM, where it was acknowledged that the facility did not meet the staffing requirements.
Plan Of Correction
1. Minimum required 3.20 hours of direct patient care noted to be deficient cannot be corrected as this is a past event. 2. PPD will be calculated in advance and updated daily based on census to ensure facility is meeting PPD requirement by the Scheduler and DON/Designee. 3. Re-education to Scheduler and Nursing Administrative Staff regarding the required PPD to be completed. Facility is increasing its presence with advertising on social media in regards to promoting/advertising open positions and vetting applicants; Agency rate has been increased and shift bonus being offered. HR attends job fairs as they are available. Tuition reimbursement and referral bonus are all in place as incentive for recruiting and committal purposes. 4. PPD will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 02/04/2025.