Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required general nursing care hours to each resident daily. A review of the facility's staffing levels revealed that on December 31, 2024, the facility provided only 2.92 direct care nursing hours per resident, which is below the mandated minimum of 3.2 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 2, 2025, at 11:00 AM, who acknowledged the failure to meet the required staffing levels.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of general nursing care hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated general nursing hours of 3.20 hours of general nursing care to each resident. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of direct care nursing hours per resident. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum of 3.20 hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and.