Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. On December 22, 2024, the facility provided 3.07 hours, on December 24, 2024, 3.13 hours, and on December 25, 2024, only 2.69 hours of direct care per resident. These staffing levels were below the mandated minimum requirement. An interview with the Nursing Home Administrator on December 30, 2024, confirmed the facility's failure to provide the required minimum general nursing care hours to each resident daily.
Plan Of Correction
1. The facility cannot retroactively correct staffing PPD. 2. DON/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. DON/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. DON/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.