Observations:
Based on review of nursing time schedules and staff interview, it was determined that the facility failed to provide the minimum number of general nursing hours for each resident in a 24-hour period on three of 21 days (6/11/22, 6/12/22, and 6/13/22).
Findings include:
Nursing time schedules for the dates of 6/9/22, through 6/15/22, indicated that the facility failed to maintain 2.7 hours of general nursing care per person per day (PPD) in a 24-hour period as required on the following dates:
6/11/22- PPD 2.31
6/12/22-PPD 2.21
6/13/22-PPD 2.36
During an interview on 6/16/22, at 2:05 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the nursing hour requirements for three of 21 days.
| | Plan of Correction - To be completed: 06/30/2022
1. No residents were negatively affected by this deficient practice.
2. The facility scheduler will be educated by the Nursing Home Administrator on scheduling at a minimum of 3.0 PPD consistently.
3. The Director of Nursing, Assistant Director of Nursing, Scheduler, and Nursing Home Administrator will have a daily staffing meeting five times per week to ensure that the PPD is above the state regulatory minimum 2.7 for the current day as well as future days.
4. PPD will be monitored using an audit tool by the NHA or designee five times per week to ensure staffing remains above 2.7. This audit will be done daily for three months, then weekly for three months, then monthly thereafter.
5. Additional agency contracts will be explored to assist in obtaining more staff at the facility.
6. Results of audits will be reviewed at monthly QAPI meeting for follow up recommendations, actions, and progress.
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