Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.20 hours of direct nursing care per resident per day on three specific dates. On December 20 and 21, 2024, the facility provided 3.15 and 3.14 hours of direct care per resident, respectively. Additionally, on March 16, 2025, the facility provided only 2.81 hours of direct care per resident. These deficiencies were identified through a review of staffing information provided by the facility for the periods of December 16 - 22, 2024, and March 13 - 19, 2025. The Nursing Home Administrator confirmed the shortfall in direct care hours during an interview on March 20, 2025.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Staffing PPD for December 20th and 21st, 2024; March 16th, 2025 were under the minimum staffing PPD of 3.20. The facility has robust retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required PPD through bonuses, day off on another day, split shifts, extra day pay. All unscheduled staff were contacted and supplemental staffing were contacted to send replacement staff with little avail. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. There were no negative outcomes to residents. The facility will continue to ensure schedule reflects the required PPD and address call offs. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. 2. No residents were affected. 3. To prevent this from reoccurring, the NHA/designee completed education with the staffing coordinators to schedule the staffing for 3.20 and above to maintain required PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly x 2 Weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.