Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels indicated that on January 12, 2025, the facility provided only 3.01 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Director of Nursing on January 16, 2025, who acknowledged the failure to meet the required nursing care hours consistently.
Plan Of Correction
1. The facility is unable to retroactively correct PPD for dates cited. 2. A facility wide audit was completed to ensure the minimum PPD of 3.2 hours are met daily for each resident. 3. The DON/Designee were reeducated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 3.2 hours. The DON will review the census daily to ensure 3.2 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to adjust the schedule by filling any gaps with per diem staff. The facility continues all effort to recruit and hire licensed staff. 4. The DON/Designee will conduct an audit of daily staffing sheets weekly x 4 weeks and then monthly x 2 months to ensure facility meets the minimum daily 3.2 nursing hours for each resident. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.