Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels revealed that on several dates, including December 22, 25, 27, 29, 30, 2024, and January 1, 2025, the facility provided less than the required nursing care hours, with figures ranging from 2.88 to 3.19 hours per resident. An interview with the Nursing Home Administrator confirmed the facility's inability to meet the mandated staffing levels on these dates.
Plan Of Correction
The facility cannot retroactively correct the per patient hours on past days identified. The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. Facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.