Based on a review of nursing schedules, 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 one of 21 days reviewed (5/15/22).
During a review of nursing schedules between 5/1/22 through 5/07/22, 5/15/22 through 5/21/22, and 5/25/22 through 5/31/22, it was revealed that the hours of direct resident care was below the 2.7 minimum per patient day (PPD) on the following date:
During an interview on 6/01/22, 11:44 a.m. the Director of Nursing confirmed that the facility did not meet the 2.7 minimum hours of direct resident care on the 5/15/22.
| ||Plan of Correction - To be completed: 06/30/2022|
1. A daily staffing meeting including the NHA, DON, Staffing Coordinator, HR, or designees, is in place to monitor projected and final PPD staffing ratios, with staffing coordinator offering bonuses for vacant shifts to staff as well as reaching out to PRN staff and agencies to fill shifts for call offs. Facility will continue practice of not accepting admissions when staffing is projected to be below state minimum. Facility has hired many nursing staff over the past several weeks, and continue to actively recruit and advertise to new and former employees.
2. Staffing Coordinator will be educated by DON/designee to document efforts of procuring sufficient staff.
3. Audits of nursing staffing will be conducted by Director of Nursing or designee daily x 2 weeks, weekly x 4 weeks, and monthly x 3 months, with incidents of staffing under 2.7 reported to DOH.
4. Results of audits with recommendations for changes will be submitted to QAPI committee.