Observations:
Based on review of nursing schedules and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 2.7 hours of direct resident care hours per resident in a twenty-four hour period for six of 23 days reviewed (5/6/22, 5/20/22, 5/25/22, 5/26/22, 5/27/22 and 5/28/22).
Findings include:
During a review of nursing schedules between 5/6/22 through 5/28/22, it was identified that the hours of direct resident care was below the 2.7 minimum per patient day (PPD) on the following dates:
5/6/22PPD 2.65
5/20/22PPD 2.60
5/25/22 PPD 2.57
5/26/22PPD 2.46
5/27/22 PPD 2.48
5/28/22PPD 2.56
During an interview on 5/28/22, at around 12:44 p.m. Employee E1 confirmed that the facility did not meet the 2.7 minimum hours of direct resident care on the dates identified above.
| | Plan of Correction - To be completed: 06/16/2022
Administrator held a meeting on May 28,2022 following the complaint survey exit for Snyder Memorial HCC with the Director of Nursing, Staffing Coordinator and Nurse Aide Supervisor. Administrator requested the Director of Nursing immediately review with all Nursing Supervisors, Charge Nurses and the Nurse Aide Supervisor the process of replacing call offs or managing extreme staffing shortages, also the need to notify Administration to include either the Director of Nursing and or the Nursing Home Administrator of significant call offs or changes with the Nursing and CNA schedules that may contribute to the facility overall ppd being lower than the Pennsylvania expected pdd of 2.70. It is not a practice of the facility to mandate staff but every attempt would be made to encourage staff to extend their shift until another care giver is able to replace them. The Nursing Supervisor, Nurse Aide Supervisor, Staffing Coordinator or designee will continue to notify all available Snyder Memorial Nurses and Certified Nursing Assistants of all staffing needs, then pursue the same effort with all facility approved staffing agencies if unsuccessful. If appropriate replacements "are not found", the Director of Nursing and or Administrator will involve the Management Nurses to assist with the staffing need.
In a effort to successfully recruit future staff the facility is working with Corporate Human Resources and offers a competitive wage and benefit package with incentives. This recruitment effort includes recruitment of unlicensed staff for our Nursing Assistant classes. At the present time we regularly utilize six staffing agencies and they have been able to meet our overall needs.
To assure future compliance with the staffing ppd the Director of Nursing will complete a daily check of the staffing hours, in her absence the Clinical Director or Mid Night Supervisor will support. A new daily audit form has been established and will be maintained until staffing challenges are improved and or the facility Quality Assurance team agrees the audits are no longer needed. In addition to the daily checks the Administrator will be notified immediately by Nursing Management of any concerns with ppd. A
Quality Assurance meeting has been scheduled for June 16, 2022 to review the citation and plan of correction. Any suggestions or recommended adjustments to the plan of correction will be implemented as per committee outcome.
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