(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 staffing information furnished by the facility and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hour period be a required minimum of 2.87 hours of direct care for each resident for one of seven days reviewed (February 11, 2024).
Findings Include:
Review of staffing information provided by the facility dated February 6, 2024, through February 12, 2024, revealed the facility provided the following direct care hours for each resident: February 11, 2024, 2.70 hours; therefore, not meeting the state minimum of 2.87 direct care hours per resident per day.
An interview with the Nursing Home Administrator on February 22, 2024, at 2:40 PM, revealed the facility continues to struggle with meeting the required minimum hours; and on February 11, 2024, four Nursing Assistants called off from work.
| | Plan of Correction - To be completed: 02/29/2024
Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.
Residents continued to receive care during the days the direct care hours fell below the minimum staffing of 2.87 direct care hours per resident per day.
The facility has identified that all the residents have the potential to be affected by the minimum direct care hours of 2.87 per resident per day.
Facility will review the daily attendance report 3x daily to ensure fulfillment of the 2.87 minimum direct care hours of 2.87 per resident per day. Facility has been enrolling candidates monthly into a local CNA course and will begin full time employment with the facility upon completion. RN Supervisors will utilize staff call list and contracted agency when there are staff call offs.
HR Director/Designee will conduct 3 random audits weekly for 1 month, and then 3 random audits monthly, for the minimum of 2.87 direct care hours to be provided per resident per day. HR/Designee will report audit results monthly for Quality Assurance and Performance Improvement Committee to address the need for further review.
Date of compliance 2/29/24.
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