Failure to Meet Minimum Direct 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 patient daily (PPD) on three specific days. A review of nursing time schedules and staff interviews revealed that on February 28, 2025, the facility provided 3.12 PPD, on March 1, 2025, 2.97 PPD, and on March 2, 2025, 2.87 PPD. This deficiency was confirmed during an interview with the Director of Nursing on March 5, 2025, who acknowledged the shortfall in meeting the required PPD hours on the specified dates.
Plan Of Correction
DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler will be reeducated on after hours call ins in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. 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.