Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility administrative staff failed to provide the minimum required number of general nursing hours to each resident in a 24-hour period on four specific days: December 14, 15, 23, and 25, 2024. A review of nursing schedules and census information revealed that on these dates, the facility did not meet the mandated 3.2 hours of direct resident care per resident per day. Specifically, the facility provided 3.10, 2.99, 3.11, and 2.95 hours per resident on the respective dates, falling short of the regulatory requirement. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on December 26, 2024.
Plan Of Correction
A follow-up review on 12/27/2024 of the nursing schedules and census information. DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler was hired to perform scheduling duties after hours in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly x 2 weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.