Deficiency in Meeting Required 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 on three out of six days reviewed. Specifically, the facility provided only 3.07 hours on March 25, 3.15 hours on March 29, and 2.87 hours on March 30, 2025. This deficiency was identified through a review of nursing time schedules and confirmed during an interview with the Director of Nursing on April 1, 2025, who acknowledged the shortfall in meeting the required care hours on the specified days.
Plan Of Correction
1. Facility unable to correct the staffing hours on the cited dates; efforts are continuously being made to maintain the staffing hours within regulatory guidelines. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit direct care staffing hours five times per week to ensure regulatory compliance. The facility will continue with recruiting efforts, as well as offering employment incentives in order to increase staff availability. When there are staffing challenges, administrative staff can/will assist with mealtime, answering call bells, etc. When there is a call off, the scheduler makes contact with all staff via phone/text to find coverage. We encourage staff to take turns in staying beyond their regularly scheduled shift to cover call offs. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance committee for review and recommendations.