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 ten out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents for the period from November 20, 2024, to December 3, 2024. On specific dates, the facility's nursing care hours per patient day (PPD) fell below the required minimum, with the lowest being 2.81 PPD on December 1, 2024. This shortfall was confirmed by the Nursing Home Administrator during a telephone interview on December 13, 2024.
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 each 24-hour period. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to current censuses. Census will be reviewed to ensure staff to resident ratio and PPD. 2. The facility will utilize administrative staff that have RN, LPN licensure and/or CNA in good standing to maintain the required 3.2 hours of direct patient care, in the event of unforeseen staff shortage. 3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 5. Offer a referral bonus to employees that encourage candidates to apply. 6. The Administrator and his designees will review the staffing concerns in Monthly QAPI meetings as needed. 7. Scheduler and Nursing Supervisors will be educated on requirements of staffing needs in order to meet mandatory minimum of 3.2 hours of direct resident care for each resident in each 24-hour period. 8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible. 9. Active recruitment of potential employees of expected medical facility closings will be documented by Human Resource Director. 10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.