Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required 3.2 hours of direct general nursing care per resident in a 24-hour period, as mandated by regulation effective July 1, 2024. A review of staffing levels and resident census revealed that on several specific dates, the facility's direct care nursing hours per resident fell below the required threshold, with recorded hours ranging from 3.11 to 3.18. These deficiencies were identified through documentation review and confirmed during staff interviews. An interview with the Director of Nursing further substantiated that the facility did not meet the minimum general nursing care hours on the dates in question. No additional details regarding the medical history or condition of individual residents were provided in the report. The findings are based solely on staffing records and staff confirmation.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility is actively recruiting for all nursing positions, offering sign-on and referral bonuses. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.