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 per 24-hour period, as mandated by regulation effective July 1, 2024. A review of staffing records revealed that on 17 out of 21 days reviewed, the facility's nursing hours fell below this minimum threshold. Specific dates were identified where the direct care nursing hours per resident ranged from 2.71 to 3.16, all below the required standard except for one day. An interview with the Director of Nursing confirmed that the facility did not consistently meet the required nursing care hours for each resident on a daily basis. The deficiency was identified through a combination of staffing level reviews and staff interviews, with no additional information provided regarding the medical history or condition of individual residents at the time of the deficiency.
Plan Of Correction
The facility cannot correct the inability to meet the minimum nurse staffing of 3.2 hours of general nursing care to each resident on the cited dates; however, efforts are continuously being made to maintain staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff by participating in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing PPD requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit daily nursing hours weekly for 4 weeks, and then monthly for 2 months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.