Deficiency in 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 in a 24-hour period. This deficiency was identified during a review of nursing schedules over three separate weeks. Specifically, on Sunday, October 6, 2024, the facility provided only 3.08 hours of care per resident, falling short of the mandated minimum care hours.
Plan Of Correction
Director of Nursing will in-service Staffing Coordinator, ADON's, Nursing Supervisors and Unit Managers regarding minimum of 3.2 hours of direct resident care for each resident. Director of Nursing, Administrator, Associate Administrator, Staffing Coordinators, and ADON's will continue to review staffing daily to ensure facility meets staffing ratios. DON will report anytime the minimum of 3.2 hours of direct care for the entire facility to the Administrator. Director of Nursing/Designee will continue to actively pursue applicants for nursing positions to assure staffing to resident ratios are met every shift. Staffing to resident ratios will be reviewed at QAPI meetings.