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 resident care per patient day (PPD) for four out of eight days reviewed. Specifically, on December 26, 2024, the facility provided 2.97 hours PPD; on December 29, 2024, 2.65 hours PPD; on December 31, 2024, 2.44 hours PPD; and on January 2, 2025, 3.13 hours PPD. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025, at 1:17 PM.
Plan Of Correction
The Facility is unable to correct the past issue of not meeting the 3.2 daily Nursing PPD requirement. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to recruit for open RN, LPN, and CNA positions using online sites, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased to try to assist with staffing. Shift bonuses are also offered as necessary to Facility staff to fill open shifts. The Facility continues to conduct daily staffing meetings to ensure efforts were made to meet the daily PPD requirement. The DON/Designee will audit the daily PPD weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reviewed at the monthly QAPI meeting.