Facility Fails to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios, as confirmed by an interview with the Nursing Home Administrator on January 14, 2025. The regulation effective July 1, 2024, mandates a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. However, a review of the facility's staffing levels revealed that on several dates in January 2025, the facility did not meet this requirement. Specifically, on January 7, 9, 10, 11, 12, and 13, the facility provided less than the required 3.2 hours of direct care nursing per resident, with the lowest being 2.95 hours on January 10, 2025. This deficiency was confirmed through a review of nurse staffing, state regulation, and staff interviews.
Plan Of Correction
The facility cannot retroactively correct the nursing care state minimum hours. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing, and Nursing Home Administrator to review the current day nursing of minimum care state hours each day of 3.20 and review the upcoming days of the week and following week to ensure appropriate nursing minimum care state hours each day of 3.20. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through the efforts of the Human Resources manager and the Administrator working on the facility recruitment and retention plan to maintain required minimum state daily nursing hours of 3.2 PPD. If the projected daily state minimum staffing ratios do not meet minimum, then the facility will reach out to current staff and staffing agency using as needed bonuses to enlist staff or agency staff to meet the state minimum hours required. The facility will continue to recruit staff through all platforms over the next 90 days to hire and retain staff to meet the state daily nursing care hours of 3.2. Daily audits by the NHA or designee of the daily minimum state nursing care hours will be conducted for 7 days and weekly for 2 weeks. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state minimum general nursing care hours can be met through the hiring and retention plan over the next 90 days.