(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.
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Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 direct care hours for each resident for three of three days reviewed.
Findings include:
Review of nursing schedules for three days from July 26 through 28, 2024, revealed the following nursing care hours below minimum requirements:
July 26, 2024, 2.71 care hours per resident.
July 27, 2024, 2.75 care hours per resident.
July 28, 2024, 2.67 care hours per resident.
| | Plan of Correction - To be completed: 08/30/2024
1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
5. Results will be taken to the QAPI for review and revision as needed.
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