(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
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Observations:
Based on a review of facility nursing staffing schedules and interview with staff, it was determined that the facility failed to meet the minimum number of nursing care hours for each 24-hour period for four of 21 days reviewed. (March 5, 2023, March 11, 2023, March 12, 2023, March 13, 2023)
Findings include:
A review of nursing schedules from March 4, 2023, through March 26, 2023, revealed that the facility failed to meet the minimum number of nursing hours of 2.7 hours of direct resident care for each resident on five of seven days reviewed as follows: Sunday, March 5, 2023, was 2.52 hours of direct resident care. Saturday, March 11, 2023, was 2.33 hours of direct resident care. Sunday, March 12, 2023, was 2.40 hours of direct resident care. Monday, March 13, 2023, was 2.67 hours of direct resident care.
An interview with the Nursing Home Administrator, on Tuesday, March 28, 2023, at 2:05 p.m. confirmed that the three weeks of schedules were provided for review, and were as worked for each day requested.
28 Pa. Code 211.12(i) Nursing services
| | Plan of Correction - To be completed: 04/25/2023
This provided submits the following plan of correction in good faith and to comply with State and Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
An audit of schedules for 2 weeks has been completed to meet the minimum number of nursing hours of 2.7 hours of direct resident care for each resident. The DON/Scheduler and Nursing Supervisors have been educated on the daily minimum number of nursing hours of 2.7 hours of direct care for each resident by the NHA/designee. The NHA/designee will complete weekly audits times four weeks of daily schedules and monthly times two months to ensure the daily minimum nursing hours of 2.7 hours of direct care for each resident. Results of these audits will be submitted to the Quality Assurance committee to determine if further action is needed.
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