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 14 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing documents and confirmed by the Nursing Home Administrator during a telephone interview. On specific dates, the facility's nursing care hours per patient day (PPD) fell below the required minimum, with the lowest recorded at 2.84 PPD. This shortfall in nursing care hours was documented on multiple occasions, indicating a consistent failure to meet the mandated staffing levels over the reviewed period.
Plan Of Correction
The facility must maintain the minimum of 3.20 general nursing care hours for each 24-hour period. To ensure that this regulatory requirement is met, the following will be implemented: The scheduler was reeducated on 4/28/25 to ensure that they understand the regulatory requirement for general nursing care hours. The nursing schedule will be reviewed by the scheduler and Director of Nursing to ensure that general nursing care hours are met prior to posting of the schedule. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure that general nursing care hours are met. Bonuses will be offered as an incentive for employees to cover shifts. In addition, the facility utilizes a recruitment company to attract additional staff. An audit will be developed and completed by the Director of Nursing or Designee 3 times per week for 4 weeks, then 2 times a week for 3 weeks, then weekly ongoing, to ensure that the minimum of 3.20 general nursing care hours for a 24-hour period is met. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.