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 ten out of eighteen days. This deficiency was identified through a review of nursing schedules and census information from December 1, 2024, to December 18, 2024. On specific dates, the facility's provided nursing care hours per resident per day (PPD) fell below the required threshold, with PPDs ranging from 2.91 to 3.19. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an interview conducted on December 19, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased HPPD on 12/1/24 through 12/17/24. The Director of Nursing, HR and Scheduler will be re-educated on the state requirement for HPPD by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 3.2 HPPD, then the facility will reach out to current staff and staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.