Deficiency in 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. This deficiency was identified during a review of nursing schedules over a 21-day period, specifically on four days: March 15, April 25, April 26, and April 27, 2025. On these days, the facility provided 3.11, 3.05, 3.10, and 2.86 hours of care per resident, respectively, which were below the mandated minimum. The facility administrator confirmed the shortfall in nursing care hours during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with a minimum of 3.2 hours of direct care for each resident daily. 2. A comprehensive review of the resident census and care needs was conducted to verify that current nursing staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast nursing staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff received training on regulatory minimum 3.2 hours of direct care for each resident daily. 4. Daily audits of a minimum of 3.2 hours of direct care for each resident daily will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.