(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.
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Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on 11 of 21 days (12/25/24, 12/26/24, 12/29/24, 1/1/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/11/25, and 1/12/25).
Findings include:
Review of the nursing schedules and census information for 12/24/24, through 1/13/25, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:
- 12/25/24, Census 168, PPD 3.11
- 12/26/25, Census 168, PPD 2.95
- 12/29/24, Census 163, PPD 3.11
- 1/1/25, Census 165, PPD 3.05
- 1/3/25, Census 165, PPD 2.96
- 1/5/25, Census 167, PPD 2.99
- 1/6/25, Census 168, PPD 2.97
- 1/7/25, Census 167, PPD 3.10
- 1/8/25, Census 166, PPD 3.13
- 1/11/25, Census 168, PPD 3.14
- 1/12/25, Census 167, PPD 3.09
During an interview on 1/16/25, at 2:20 p.m., the Nursing Home Administrator (NHA) confirmed that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on 11 of 21 days (12/25/24, 12/26/24, 12/29/24, 1/1/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/11/25, and 1/12/25).
| | Plan of Correction - To be completed: 02/19/2025
No residents were affected during
the days identified in the 2567. The
Director of Nursing
and Staffing Coordinator were
re-educated regarding minimum
staffing PPD (per patient day) by the
Administrator.
The facility has previously reviewed
the staffing plan and has assessed
wages, provided extra shift pick up
bonuses to qualified staff, provided
for flexible scheduling, and has
advertised in several ways for staff
including on online help wanted
sites.
The facility will send representatives
to local job fairs, partnered with local
businesses such as job corps, each
morning the administration staff
meets to review the staffing for the
day and any critical days in the
future, weekly staffing meetings,
staffing to include increased
employees to cover for any call offs,
progressive disciplinary action if
necessary and weekly review of new
staff that has been hired and will be
joining the facility team in the future
and any staff that has resigned or
has been terminated. Corporate
leadership included on strategies
and any needs of the facility.
The Nursing Home Administrator,
Director of Nursing, and Staffing
Coordinator, or designees, will
review the ratios daily and look
ahead in the upcoming week
schedule.
The Director of Nursing or designee
will monitor the PPD 5 times a week
for 4 weeks then weekly X4.
Results of audits will be reviewed at
the facilities quality assurance
performance improvement meeting.
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