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 in a 24-hour period on six specific days within a 21-day timeframe. The nursing time schedules from January 1, 2025, to January 21, 2025, revealed deficiencies in staffing levels on January 5, 7, 9, 13, 17, and 19, 2025, with recorded nursing care hours ranging from 2.80 to 3.10 hours per resident. This shortfall was confirmed by the Nursing Home Administrator during an interview on January 23, 2025, indicating a failure to comply with the mandated staffing levels on those dates.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on minimum overall nursing hour staffing to include expectations of HPPD and ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review ratio and PPD compliance for upcoming schedules. DON/ designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.