Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct general nursing care per resident per day for two out of twenty-one days reviewed. Specifically, on two dates, the provided nursing care hours were 3.16 and 3.14 per patient day, which is below the regulatory standard. This was confirmed through a review of facility nursing staffing documents covering several periods and was acknowledged by the Nursing Home Administrator during an interview. No additional details about specific residents or their conditions were provided in the report.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility shall utilize the following process: 1. In an attempt to achieve general nursing care hours of at least a minimum of 3.2 hours of direct resident care hours per resident in a 24-hour period, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of direct care staff in relation to Resident census. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing PPD's on a daily basis utilizing the DOH staffing calculation tool until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee. 5. The scheduler and RN Supervisors will be re-educated on the regulatory guidelines for the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period. This will be the responsibility of the Director of Nursing.