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 nursing care per resident per day for four out of eleven days reviewed. Specifically, on the dates of 1/26/25, 2/01/25, 2/02/25, and 2/04/25, the facility's nursing staffing documents showed that the general nursing care hours were below the required minimum, with recorded hours of 3.19, 3.14, 3.05, and 3.03 PPD, respectively. This deficiency was confirmed during a telephone interview with the Nursing Home Administrator on 2/06/25, who acknowledged that the facility did not meet the required nursing care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the State required PPD (per patient day) minimum hours of 3.20 was not met on 1/26, 2/1, 2/2, and 2/4/25. 2. Nursing supervisors will be re-educated regarding the daily PPD by the Director of Nursing/or Designee. 3. Daily meetings will be held to review the schedule with PPD. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing PPD, the scheduler/or designee will call off duty facility staff, notify the Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment. 6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 7. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. DON or designee will monitor staffing PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days, then weekly x 6 weeks, then Q monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.