Facility Fails 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 resident care per day for each resident. This deficiency was identified through a review of nursing schedules over a 21-day period from January 11 to January 31, 2025. During this period, the facility consistently provided less than the required hours of care, with daily averages ranging from 2.55 to 3.09 hours per resident. The shortfall in nursing care hours was confirmed by the Nursing Home Administrator during an interview on February 1, 2025. The deficiency affected all residents in the facility, as the nursing care hours were below the mandated minimum for each day reviewed. The facility's inability to meet the required care hours suggests a systemic issue in staffing or scheduling that impacted the delivery of care to residents. The report does not provide specific details about the residents' medical conditions or the direct impact of the deficiency on their health, but it highlights a failure to comply with the established care standards.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily. 2. In the event of call offs, the center follows staffing procedures including exhausting all possible replacements from internal staffing pool and contracted agency staff. The center continues to offer incentives, coordinate staffing schedules, and replace call offs per protocol while actively continuing to hire for all open positions and additional pool staff. 3. All registered nurses and the scheduler have been educated on the 7/01/2024 HPPD and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON/designee will audit staffing weekly for 4 weeks, then monthly for 2 months. Results will be reviewed by the QAPI Committee for recommendations as needed.