Deficiency in Meeting 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 patient per day (PPD) for four specific days across three different periods. The review of nursing staff care hours revealed deficiencies on October 6, 11, and 12, 2024, and November 24, 2024, with PPD hours recorded as 3.17, 3.08, 3.14, and 3.18, respectively. This shortfall was identified during a review of nursing staffing hours and confirmed through staff interviews. The findings were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct staffing PPD. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. Director of Nursing/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.