Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct nursing care per resident per day on six out of seven days reviewed. Specifically, on December 4, 5, 7, 8, 9, and 10, 2024, the facility provided between 2.84 and 3.11 hours of direct care per resident, falling short of the mandated requirement. This deficiency was confirmed through a review of the facility's staffing levels and an interview with the Director of Nursing on January 2, 2025, who acknowledged the failure to meet the staffing requirements consistently.
Plan Of Correction
P5640 Nursing Services 1. The facility is unable to correct PPDs for December 4, 2024, December 5, 2024, December 7, 2024, December 8, 2024, December 9, 2024, and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and the scheduler to maintain a PPD of 3.2. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4, biweekly x4, and monthly x2 to ensure the PPD has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025