Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility administrative staff failed to provide the minimum required 3.2 hours of direct resident care per resident in a 24-hour period on six specific days between April 3, 2025, and April 11, 2025. This deficiency was identified through a review of nursing schedules and census information, which revealed that the provided hours per patient day (PPD) fell short of the mandated requirement on these dates. Specifically, the PPD was 3.16 on April 3 and 4, 3.14 on April 5, 3.19 on April 8, 2.97 on April 10, and 3.13 on April 11. The Nursing Home Administrator confirmed this shortfall during a follow-up communication on April 21, 2025.
Plan Of Correction
The Staffing Coordinator will implement a daily tracking process in the facility software program to monitor projected and actual nursing hours PPD. This tool will calculate staffing requirements based on daily census and will be reviewed by the Administrator each morning to ensure adequate coverage. If staffing levels are projected to fall below the minimum threshold, the Coordinator will call-in procedure to utilize PRN staff, float pool personnel, or approved agency staff. The facility will also continue recruiting methods to bring more staff in. Administrative staff will be re-educated on minimum nursing hour requirements and their role in meeting them. Daily staffing logs will be audited for 30 days beginning June 9, and results will be reviewed weekly in QAPI meetings. To ensure sustained compliance, the DON or designee will conduct weekly audits of the prior week's staffing logs for accuracy and completeness. These audits will confirm that the 3.2 PPD minimum is met, verify proper documentation of census and hours, and confirm any corrective actions taken if shortfalls occur. Results of these audits will be reviewed weekly during QAPI meetings. Following the initial 30-day audit period, the facility will transition to monthly staffing audits for the remainder of the calendar year to monitor long-term compliance.