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. This deficiency was identified during a review of nursing schedules for the period from January 1 through January 21, 2025. Specifically, on three days within this period, the facility did not meet the required care hours. On January 17, 2025, the facility provided 3.11 care hours per resident, on January 19, 2025, it provided 2.79 care hours per resident, and on January 20, 2025, it provided 3.05 care hours per resident. These findings indicate a shortfall in the required nursing care hours on these specific days.
Plan Of Correction
1. Staffing Manager or designee will staff the daily nursing staff to meet the minimum nursing staff to resident ratios and maintain a minimum of 3.2 hours of direct care for each resident. 2. NHA, DON, Staffing Coordinator reinserviced on new staffing ratio / PPD requirements. 3. Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software. 4. Reports will be reviewed at monthly QAPI meetings.