Based on review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.7 hours of direct resident care for each resident.
A review of facility nurse staffing data, including deployment sheets for the week of May 4, 2022, through May 10, 2022, and June 22, 2022, through June 28, 2022, the facility's 24 hour daily nurse staffing nurse staffing was below 2.7 hours per resident on the following day:
June 23, 2022, nursing hours of direct resident care for each resident was 2.68.
Interview with the Nursing Home Administrator (NHA) on June 29, 2022, at approximately 2:10 P.M. confirmed the nursing hours indicated above.
| ||Plan of Correction - To be completed: 07/20/2022|
The facility will provide staffing at a minimum of 2.7 hour per patient day or higher to meet the needs of the residents. The nursing schedule and deployment sheets will be reviewed daily Monday through Friday, to include projected weekend hours, by the Administrator, Director of Nursing, and Center Scheduling Manager to validate appropriate direct resident care hours are being met and adjustments will be made if necessary.
Facility residents have the potential to be affected by this practice.
The Administrator, Nursing Management team, and Center Scheduling Manager will be re-educated concerning minimum nursing staffing hours, the calculation of direct resident care hours, and the appropriate response to unplanned variations in hours.
Administrator/designee will audit the direct care hours during the daily review of nursing schedules and deployment sheets to ensure that 2.7 hours of direct resident care or more is maintained.
Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.