Based on review of facility nurse staffing data and staff interview it was determined that the facility failed to maintain a minimum of 2.7 nursing hours of direct resident care in a 24 hour- period for each resident.
A review of facility nurse staffing data, including deployment sheets for the week of April 6, 2019, through April 12, 2019, revealed that the facility's 24 hour daily nurse staffing nurse staffing was below 2.7 hrs per resident on the following days:
April 6, 2019 - nursing hours of direct resident care for each resident was 2.43
April 6, 2019 - nursing hours of direct resident care for each resident was 2.57
Interview with the Administrator on May 15, 2019 at 12:30 p.m. confirmed the nursing hours indicated above and the facility's failure to consistently provide the minimum general nursing care hours to each resident daily.
| ||Plan of Correction - To be completed: 05/28/2019|
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is required by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of May 28, 2019.
- The facility cannot retroactivity correct the deficiency noted by the surveyors related to April 6 and April 12, 2019 Nursing Hours.
- The staffing coordinator will be re-educated on the minimum Nursing Hours requirements by the Director of Nursing or designee.
- The Director of Nursing or designee will review staffing sheets with the staffing coordinator daily for 4 weeks and then weekly for 2 months to verify appropriate Nursing staff levels.
- The Nursing Home Administrator or designee will randomly audit staffing sheet weekly for 4 weeks and then monthly for 2 months to verify compliance.
- Audits will be reviewed at the monthly QAPI meetings and the Director of Nursing or designee will immediately address any concerns.