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 resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by an interview with the Director of Nursing. On six out of the seven days reviewed, the facility's staffing levels were below the required minimum, with direct care nursing hours per resident ranging from 2.55 to 3.01 hours. Specific dates where the facility fell short include December 20, 21, 23, 24, 25, and 26, 2024. The Director of Nursing confirmed the inconsistency in meeting the required nursing care hours during an interview conducted on January 2, 2025.
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 a 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.