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. This deficiency was identified during a review of the facility's nursing staffing documents for the period from November 21, 2024, to December 4, 2024. Specifically, on November 30, 2024, the facility provided only 2.94 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on December 23, 2024.
Plan Of Correction
1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional staff will be scheduled proactively on days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels, staff ratios throughout the day and night shifts, and to meet a minimum of 3.2 hours of direct resident care hours and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that the 3.2 minimum hours of direct resident care for each resident are met. The Nursing Home Administrator will review staffing ratios and resident care hours are met against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.