Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 2.87 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's staffing levels, which revealed that on three specific dates, the facility provided only 2.56 and 2.55 hours of direct care nursing per resident. These dates were December 21, 24, and 25, 2024. An interview with the Director of Nursing confirmed the facility's failure to consistently meet the required nursing care hours on these days.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.