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 resident in a 24-hour period for 10 out of 14 days reviewed. The deficiency was identified through a review of nursing staffing documents covering the period from January 8, 2025, to January 21, 2025. On several specific dates, the facility's direct care hours per patient per day (PPD) fell below the required minimum, with the lowest being 2.62 hours on January 11, 2025. This shortfall was confirmed by the Nursing Home Administrator during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5640 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, Director of Nursing/DON and assistant director of nursing and charge nurses on the state required minimum staffing levels of 3.2 hours per patient day. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/designee to conduct staffing meetings 3 times weekly to ensure the state required minimum number of general nursing care hours are met through the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. NHA/designee to review staffing sheets 3x weekly to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required minimum staffing hours of 3.2, interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Nursing staff are offered call-in- bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs. 4. How the corrective action(s) will be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review nursing schedule and projected daily minimum number of general nursing care hours to ensure the minimum 3.2 hours are met. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality and performance improvement process. 5. Dates when corrective action will be completed. March 3, 2025