Observations:
Based on review of facility nursing staffing information and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period for seven of seven days reviewed (1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, and 1/22/25.
Findings include:
Review of nursing staffing information for the time period from 1/16/25, through 1/22/25, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:
1/16/25 2.42
1/17/25 2.27
1/18/25 2.19
1/19/25 2.46
1/20/25 2.58
1/21/25 2.88
1/22/25 2.83
During an email correspondence interview on 1/25/25, at 1:49 p.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 minimum hours of direct resident care on the above dates.
| | Plan of Correction - To be completed: 03/31/2025
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Bradford Manor will be protected from future daily patient per day (PPD) ratios below 3.2 by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing (DON) or Designee. The scheduler or designee will review projected staffing levels with the DON or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable PPD levels below 3.2 are adequately covered and audit to ensure levels were met. Bradford Manor will continue to aggressively advertise externally for recruitment of nursing assistant applicants to enhance current staffing levels. Bradford Manor will continue to have open interviews weekly. Bradford Manor is an approved site of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing nurse aide training classes throughout the year. Bradford Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized to entice employees to pick up unscheduled shifts. Bradford Manor now has a recruiter on staff to assist with filling open positions. Staffing levels will be considered when reviewing referrals. Results of the audits will be reviewed at Quality Assurance Performance Improvement Meetings. Nursing Home Administrator provided education to the Director of Nursing and Human Resource Coordinator on the requirement of 3.2 hours of direct resident care hours per resident in a 24-hour period on 2/6/2025.
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