(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 a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for three of 17 days reviewed.
Review of nursing schedules for 17 days from May 19, 2024, through June 4, 2024, revealed the following total nursing care hours below minimum requirements:
Sunday May 19, 2024, 2.59 care hours per resident.
Saturday May 25, 2024, 2.80 care hours per resident.
Sunday June 2, 2024, 2.65 care hours per resident.
During an interview on June 6, 2024, at 1:30 p.m., the Director of Nursing confirmed that the facility did not meet the minimum required nursing care hours on the above dates.
| | Plan of Correction - To be completed: 07/09/2024
1. Facility is unable to retroactively correct deficiency practice
2. Facilities direct care PPD will be reviewed for the past 7 days to determine if direct care PPD was met.
3. NHA, DON and Nursing schedule coordinator will be re-educated on ratio and PPD requirements.
4. Weekly audit of direct care PPD will be completed for 60 days by NHA/designee to ensure PPD is met.
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