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 (PPD) on five out of seven days during the week of December 15, 2024. A review of the nursing staff care hours revealed that on December 15, 16, 18, and 20, 2024, the facility provided 3.11, 3.10, 3.09, and 3.12 PPD respectively, which were below the required minimum. Additionally, on December 15, 2024, the facility provided only 2.64 PPD, significantly below the required standard. An interview with the Nursing Home Administrator confirmed the staffing levels did not meet the required minimum PPD of 3.2.
Plan Of Correction
Plan of Correction for § 211.12(i)(2) Nursing Services: 1. Review of General Nursing Care Staffing Ratios: The facility reviewed the total number of general nursing care staffing ratios for December 15, 2024, December 16, 2024, December 18, 2024, December 20, 2024, and December 21, 2024. No grievances or care were affected on those dates due to staffing ratios. 2. Expanded Review: Additional dates were reviewed to ensure that ratios were met, and care affects. 3. Education on Staffing Ratios: The scheduling coordinator will be educated on general nursing care staffing ratios: - Minimum of 3.2 hours of direct resident care per resident per day. 4. Monitoring and Audits: The NHA or designee will conduct audits to verify nursing care staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. 5. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.