Failure to Meet Minimum Nursing Care Hours Requirement
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 24-hour period. A review of nursing schedules over a 21-day period revealed that, for 20 out of those 21 days, the total direct care hours per resident fell below the mandated threshold. The reported daily care hours ranged from 2.47 to 3.03, with only one day meeting or slightly exceeding the required minimum. This deficiency was identified through the examination of documented nursing time schedules for the specified period.
Plan Of Correction
Unable to correct past events. The use of an outside Recruiting Group has assisted with filling vacancies and qualified ancillary staff assist with maintaining PPD. An internal agency has been developed that does assist with providing less desirable shift (2nd and 3rd) coverage. Daily staffing huddles occur in which census, open holes, call offs, etc., are addressed. Education to be completed with Nsg Administration, Scheduling, and HR on the importance of maintaining DOH guidelines as it pertains to PPD. Audits to be completed daily by NHA/designee x4 weeks, then bi-weekly x2 weeks, then monthly x2, with results to QAPI meeting.