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 for five out of fourteen days reviewed. Specifically, on the dates of 1/25/25, 1/26/25, 1/27/25, 2/01/25, and 2/02/25, the facility's nursing staffing documents showed that the provided hours of care were below the required threshold, with recorded hours of 3.16, 2.93, 2.93, 3.06, and 3.11 respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on 2/07/25, who acknowledged that the facility did not meet the mandated minimum direct nursing care hours on the specified dates.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in a 24-hour period. The administrator, Director of Nursing, Assistant Director of Nursing, and scheduler will meet each business day, each morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to the current censuses. Census will be reviewed in each morning meeting during the weekday to ensure the resident ratio and PPD is met. The facility will utilize open shifts on the OnShift mobile app available for all staff to access. The facility will utilize administrative staff that has Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant to maintain 3.2 hours of direct patient care in the event of unforeseen staff shortage. Human Resources and Director of Nursing will continue to post ads on social media, Indeed, and community-based efforts to obtain staff. Offer a referral bonus to employees that recruit staff to apply and become hired. The administrator, Director of Nursing, and interdisciplinary team will meet monthly at the Quality Assurance Improvement Program meetings as needed. Scheduler and Nursing supervisors all will be educated on the requirements of staffing needs to meet mandatory minimum 3.2 hours of direct resident care for each resident in each 24-hour period. All the above processes will be completed by the administrator and Director of Nursing or designee and documented five times weekly at a minimum. Nursing supervisors are educated to notify the Director of Nursing and Assistant Director of Nursing as soon as possible of the staff shortage needs to cover needs as soon as possible. All admissions reviewed with Director of Nursing and Assistant Director of Nursing to ensure the ratio and PPD are being met prior to being admitted to the facility. Nursing schedule reviewed and audited each weekday for four weeks to ensure all shifts are properly covered. Director of Nursing and Assistant Director of Nursing alternate weekends with scheduler to audit. It is being audited before and after the schedule is out to ensure we meet regulations.