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 on seven specific days between January 1, 2025, and January 13, 2025. A review of the facility's nursing staffing documents revealed that the hours of direct resident care fell below the required minimum on these dates, with the lowest being 2.95 hours per patient per day on January 12, 2025. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 22, 2025, who acknowledged that the facility did not meet the required staffing levels on the specified dates.
Plan Of Correction
1. The facility was unable to make corrective action for direct care staff for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of Nursing or designee will re-educate the Labor Manager and the RN supervisors on the 7/1/2024 for direct care staff PPD requirements. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing Home Administrator, Director of Nursing, and Labor Manager will conduct daily staffing meetings Monday - Friday to review (PPD) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or Designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. DON or designee will audit daily staffing PPD along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.