Failure to Meet Minimum Nursing Hours Requirement
Penalty
Summary
The facility administrative staff failed to provide the minimum required 3.2 hours of general nursing care per resident in a 24-hour period on 11 out of 21 days. This deficiency was identified through a review of nursing time schedules and staff interviews. Specific dates where the facility did not meet the required nursing hours include 12/25/24, 12/26/24, 12/29/24, 1/1/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/11/25, and 1/12/25. The census on these days ranged from 163 to 168 residents, with the provided nursing hours per patient day (PPD) falling short of the required 3.2 hours, ranging from 2.95 to 3.14 hours. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an interview on 1/16/25.
Plan Of Correction
No residents were affected during the days identified in the 2567. The Director of Nursing and Staffing Coordinator were re-educated regarding minimum staffing PPD (per patient day) by the Administrator. The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites. The facility will send representatives to local job fairs, partnered with local businesses such as job corps. Each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary, and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included on strategies and any needs of the facility. The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule. The Director of Nursing or designee will monitor the PPD 5 times a week for 4 weeks then weekly X4. Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.