(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.
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Observations:
Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on three of six days (5/10/24, 5/12/24 and 5/13/24).
Findings include:
Nursing time schedules for the time period of 5/9/24, through 5/14/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24 hour period on the following days:
5/10/24- 2.81 PPD.
5/12/24- 2.66 PPD.
5/13/24- 2.82 PPD.
During an interview on 5/16/24, at 8:45 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet nursing hours requirements on three of six days.
| | Plan of Correction - To be completed: 06/06/2024
Unable to correct past deficient practice.
To prevent future occurrences, the Administrator, Director of Nursing, and Human Resources Coordinator will receive education on staffing requirements on nurse aide ratio and minimum per patient per day staffing hours requirements, by a Regional Clinical Support Representative.
Staffing meetings will be held 5 days per week to review ratios from the prior day(s) and the projected staffing to the upcoming week to ensure appropriate staffing levels are planned. Identified staffing needs will be offered to existing staff and contracted agencies, as needed, by the Administrator, Director of Nursing, and Human Resource Coordinator to meet requirements. The facility will continue to recruit staff through use of company platforms and recruiter representatives.
Audits of staffing ratios will be completed by the NHA/designee to ensure that the facility meets daily hours requirements and nurse aid staffing ratio requirements. Audits will be completed weekly 4x weekly for 2 weeks, 2x weekly for 2 weeks, and 1x weekly thereafter, with reporting through Quality Assurance and Process Improvement for review and/or recommendations.
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