Failure 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 nursing care per resident per day on seven specific days. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. On November 15, 16, 17, and 19, as well as December 2, 7, and 8, 2024, the facility did not provide the required hours of care. For instance, on November 15, the facility had a census of 102 residents but only provided 320.00 direct nursing staff hours, equating to 3.14 hours per resident. Similarly, on other days, the hours of care per resident fell below the mandated 3.2 hours, with the lowest being 2.90 hours on November 16 and 17. The deficiency was confirmed during a review session with the Nursing Home Administrator on December 10, 2024. The administrator acknowledged that the facility did not meet the required staffing minimum on the specified dates. The report does not provide any information about the impact on residents or any immediate consequences of this staffing shortfall. The focus remains on the facility's failure to comply with the staffing regulation as evidenced by the documented nursing hours and census data.
Plan Of Correction
Admin and DON will conduct random audits of resident charts, during those days identified as having fallen below required minimum direct care, to ensure no negative outcomes in care. Scheduler will be reeducated on required staffing for minimum direct care hours per resident. The Admin will conduct a random audit weekly to ensure facility is compliant with staffing ratios. Audit will be for x3 weeks. And monthly audit x4 months. Results will be reported to QAPI.