(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.
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Observations:
Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for three of 21 days (24-hour periods) reviewed.
Findings include:
Nursing time schedules provided by the facility for the days of January 15 through February 4, 2024, revealed that the facility provided only 2.86 hours of direct care for each resident on January 21, 2024; 2.78 hours of direct care for each resident on February 3, 2024; and 2.65 hours of direct care for each resident on February 4, 2024.
Interview with the Nursing Home Administrator on February 5, 2024, at 5:00 p.m. confirmed that the facility did not meet the required direct resident care hours on the days listed above.
| | Plan of Correction - To be completed: 02/21/2024
1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will stop admissions. We continue to meet regularly to determine We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides, Sign on Bonus Paid over 1-yr Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. Referral Bonus Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class thru an outside contractor to develop more Certified Nurse's Aides. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.
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