| (i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.|
Based on staff interview, review of nursing time schedules, and resident census information, it was determined that the facility failed to ensure sufficient staffing to provide a minimum of 2.7 hours of direct resident care for each resident on five of 21 days reviewed.
Review of facility provided staffing schedules for the 21 days from September 1-7, October 6-12, and December 1-7, revealed the staffing hours per resident failed to meet the required 2.7 hours on the following dates:
September 1, 2019, 2.68 hours
September 2, 2019, 2.68 hours
September 4, 2019, 2.62 hours
September 6, 2019, 2.67 hours
October 12, 2019, 2.64 hours
Interview with the Nursing Home Administrator on December 12, 2019, at 1:30 PM confirmed that the facility failed to ensure adequate staffing to meet the 2.7 hours of direct resident care staff as required.
| ||Plan of Correction - To be completed: 12/23/2019|
The facility reviewed staffing numbers for October and already addressed the minimum hours not being met for October 12, 2019 .The NHA brought this information to the QAPI meeting for November.
Staffing schedule and staffing hours have been reviewed daily at the morning meeting
The facility has done a look back for 14 days to assure minimum requirements were achieved
The staffing hours and schedule will be reviewed daily at the morning meeting with the DON and or designee as well as the IDT to assure the state minimum of 2.7 hours has been obtained.
The DON and or designee will audit 3 x a week x 3 weeks to assure staffing minimum of 2.7 has been obtained.
The results will again be reviewed at the next QAPI meeting for further recommendations