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 for 18 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Nursing Home Administrator. Specific dates where the facility fell short include October 3, 4, 7, 8, and 9, 2024; December 27, 28, 29, 30, and 31, 2024; January 1 and 2, 2025; and March 13, 14, 16, 17, 18, and 19, 2025. On these days, the facility's nursing care hours per patient per day (PPD) ranged from 2.28 to 3.15, consistently below the required 3.2 PPD. The deficiency was further substantiated by the facility's own records, which showed that the total nursing care hours provided were insufficient for the resident census on the specified dates. For instance, on January 2, 2025, the facility provided only 341.25 care hours for 150 residents, resulting in a PPD of 2.28, significantly below the mandated minimum. The Nursing Home Administrator acknowledged the shortfall in staffing levels during an interview conducted on March 20, 2025.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to meet the regulatory requirement. Effective July 1, 2024, the total number of hours of general nursing care provided in each 24 hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident. 3. Re-education regarding the total minimum number of direct resident care hours effective July 1, 2024, the total number of hours of general nursing care provided in each 24 hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of direct care hours will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.