Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on one of the days reviewed, specifically on 11/24/24. A review of the nursing staffing documents for the periods from 11/18/24 to 11/24/24, 12/5/24 to 11/11/24, and 12/12/24 to 12/18/24 revealed that on 11/24/24, the facility provided only 3.10 hours of direct care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on 12/19/24, who verified the accuracy of the staffing information and acknowledged the failure to meet the required care hours on the specified date.
Plan Of Correction
1. The facility cannot go back to correct identified days when the nurse aide ratio was less than required for each shift. No adverse outcomes when the nurse aide ratio was less than required per interviews with clients. 2. A daily staff hour/ratio worksheet will be utilized, which has the staff ratio calculator/nursing care hours function on it. 3. Administrator/Director of Nursing will educate staffing coordinators and RN charge nurses the week of Jan 13th on: - How to use the daily staffing sheet with ratios and nursing care hours - How to replace call offs when needed - Notifications to the appropriate Interdisciplinary Team members when staffing does not meet ratios and/or nursing care hours 4. Daily staffing meeting will be implemented with the administrator/Director of Nursing/staffing coordinator or designee to review staffing and appropriate ratios and nursing care hours. Minutes will be taken for each meeting. 5. Administration will review agency contracts to ensure they are up to date. 6. Ratio/nursing care hours audit will be completed by Administrator or designee: - 5 days a week x 4 weeks then - 3 days a week x 2 weeks then weekly thereafter 7. Audits will be taken to Quality Assurance and Performance Improvement Committee for review/discussion.