Deficiency in 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. This deficiency was identified during a review of the facility's nursing staffing sheets for the weeks spanning February 13, 2025, to March 5, 2025. On 12 out of 21 days reviewed, the facility's staffing hours fell below the required threshold. Specific days with insufficient staffing hours included February 13, 14, 15, 18, 19, 20, 21, 23, 25, 27, 28, and March 2, 2025, with the lowest recorded at 2.93 hours on February 20, 2025. The deficiency was confirmed by the facility's administrator, Employee E1, on March 6, 2025.
Plan Of Correction
Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement. NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA.