Deficiency in Meeting Required Direct 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 resident in a 24-hour period. This deficiency was identified during a review of nursing time schedules for specific periods, including November 23 through 29, 2024; December 5 through 11, 2024; and January 30 through February 5, 2025. It was found that on November 29, 2024, the facility provided only 3.11 hours of direct care per resident. This shortfall was confirmed during an interview with the Nursing Home Administrator on February 6, 2025.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to have adequate staffing. 3. Facility has contracted with temporary agencies to fill upcoming vacancies. In the case of call-offs, there is not often adequate time to find another coverage. Two upcoming nurse aide training classes will yield newly trained aides to fill vacancies on a permanent basis. Facility continues to advertise openings and opportunities. 4. Review of the daily schedule with Nursing Administration and Administrator continue. Weekly audits to ensure compliance with required direct resident care hours will be done x 4 weeks, then monthly x 2. Reviews submitted to Quality Assurance team for review. Administrator to monitor for compliance.