Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.20 hours of direct resident care per patient daily (PPD) on two specific days. A review of staffing documents and nursing staff schedules from March 3, 2025, through March 16, 2025, revealed that on March 6, 2025, the facility provided 3.18 PPD, and on March 16, 2025, it provided 3.03 PPD. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 18, 2025, who acknowledged the failure to meet the required PPD hours on the specified dates.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on minimum overall nursing hour staffing to include expectations of HPPD and ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review ratio and PPD compliance for upcoming schedules. DON/ designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.