Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet 3.2 minimum number of general nursing care hours for each 24-hour period for ten of 14 days reviewed (11/22/24, 11/23/24, 11/24/24 11/26/24, 11/28/24, 11/29/24, 11/30/24, 12/01/24, 12/02/24, and 12/03/24)
Findings include:
Review of facility nursing staffing documents for the time period of 11/20/24, through 12/03/24, revealed the following general nursing care hours was below the minimum 3.2 per patient day (PPD) on the following days:
11/22/24 2.96 PPD 11/23/24 3.05 PPD 11/24/24 3.12 PPD 11/26/24 3.17 PPD 11/28/24 3.07 PPD 11/29/24 3.14 PPD 11/30/24 3.05 PPD 12/01/24 2.81 PPD 12/02/24 2.99 PPD 12/03/24 3.08 PPD
During a telephone interview on 12/13/24, at 9:26 a.m. the Nursing Home Administrator confirmed that the facility did not meet the 3.2 minimum direct nursing care hours on the above dates.
| | Plan of Correction - To be completed: 01/22/2025
No residents were found to be negatively affected by the deficient practice of regulation.
The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in each 24-hour period.
1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to current censuses. Census will be reviewed to ensure staff to resident ratio and PPD.
2. The facility will utilize administrative staff that have RN, LPN licensure and/or CNA in good standing to maintain the required 3.2 hours of direct patient care, in the event of unforeseen staff shortage.
3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up.
4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media.
5. Offer a referral bonus to employees that encourage candidates to apply.
6. The Administrator and his designees will review the staffing concerns in Monthly QAPImeetings as needed.
7. Scheduler and Nursing Supervisors will be educated on requirements of staffing needs in order to meet mandatory minimum of 3.2 hours of direct resident care for each resident in each 24-hour period.
8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible.
9. Active recruitment of potential employees of expected medical facility closings will be documented by Human Recourse Director.
10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.
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