Facility Fails 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 day for each resident. A review of nursing schedules over a 21-day period from December 12, 2024, to January 1, 2025, revealed that the facility did not meet this requirement on 19 of those days. Specific days showed care hours as low as 2.56 per resident, with the highest being 3.18, still below the mandated minimum. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 2, 2025.
Plan Of Correction
1. The facility has reviewed past reported staffing information including PPDs. 2. Facility will review schedules and PPDs during the daily labor meetings. A variety of methods for staffing and recruitment will be utilized in order to fill vacant positions. Methods will be reviewed for effectiveness during daily labor review and adjusted according to facility need. 3. The Administrator / Designee re-educated the staffing coordinator on the policy regarding staffing, schedules, and PPD requirements. 4. The Administrator / Designee will audit schedules and PPDs 2 times per week for 2 weeks, then weekly for 4 weeks. Results of audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.