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 nursing care per resident per day. A review of nursing schedules from February 28 through March 20, 2025, revealed that on 11 out of 21 days, the facility did not meet this requirement. Specific days with deficiencies included February 28, March 1, March 2, March 3, March 6, March 9, March 13, March 14, March 15, March 17, and March 20, with care hours per resident ranging from 2.51 to 3.18, all below the mandated 3.2 hours. This indicates a consistent shortfall in staffing levels necessary to provide adequate care to residents during the specified period.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician order. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.