Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on nine out of twenty-one reviewed days. Review of nursing time schedules and census data showed that on these dates, the provided nursing hours per patient day (PPD) ranged from 2.72 to 3.18, falling short of the regulatory requirement. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler continues to perform scheduling duties after hours in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call-offs and no-shows. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly for 2 weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with the QAPI Committee during the monthly meeting to determine the need for further audits. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey