Staffing and Care Hours Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during various shifts, as confirmed by the Director of Nursing (DON) during an interview. Specifically, the facility did not provide the minimum number of LPNs per residents during the day, evening, and night shifts. Additionally, the facility did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on 17 out of 21 days, as evidenced by a review of nursing schedules and census information. The Patient Per Day (PPD) hours fell below the required threshold on multiple dates, with the lowest being 2.21 hours on one occasion. These deficiencies were acknowledged by the DON, indicating a consistent shortfall in providing adequate nursing care over the specified period.
Plan Of Correction
1. The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on 17 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that general nursing hours are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and ensuring general nursing hours to each resident are met each shift. Daily shift staffing hours will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing on the weekends. If the facility projects to not meet general nursing hours to each resident on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure general nursing hours for each resident are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.