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 ten out of fourteen days reviewed. Specifically, on the dates of 12/19/24, 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/28/24, 12/29/24, and 12/31/24, the facility's nursing staffing documents showed that the provided hours of care were below the required minimum. The recorded hours ranged from 3.07 to 3.17 hours per patient day (PPD), falling short of the mandated 3.2 PPD. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on 1/03/25.
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 12/19, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/28, 12/29, and 12/31/24. 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 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. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor PPD. This will be reviewed at the Quarterly QAPI meetings.