(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 review of nursing time schedules, punch reports and staff interviews, it was determined that the facility failed to provide a minimum of 3.20 hours of direct nursing care per resident on seven of twenty-one days reviewed (November 15, 16, 17, 19; and December 2, 7, 8, 2024).
Findings include:
Review of facility census data, punch reports and nursing time schedules revealed that on November 15, 2024, the facility census was 102, and a total of 320.00 direct nursing staff hours were provided, which equaled 3.14 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on November 16, 2024, the facility census was 102, and a total of 296.00 direct nursing staff hours were provided, which equaled 2.90 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on November 17, 2024, the facility census was 102, and a total of 296.00 direct nursing staff hours were provided, which equaled 2.90 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on November 19, 2024, the facility census was 101, and a total of 320.00 direct nursing staff hours were provided, which equaled 3.17 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on December 2, 2024, the facility census was 94, and a total of 296.00 direct nursing staff hours were provided, which equaled 3.15 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on December 7, 2024, the facility census was 98, and a total of 290.00 direct nursing staff hours were provided, which equaled 2.96 hours of direct nursing care per resident.
Review of facility census data, punch reports and nursing time schedules revealed that on December 8, 2024, the facility census was 98, and a total of 304.00 direct nursing staff hours were provided, which equaled 3.10 hours of direct nursing care per resident.
Staffing calculations, nursing staff schedules and staff punch reports were reviewed with the Nursing Home Administrator on December 10, 2024, at 5:30 p.m. The Nursing Home Administrator confirmed that the required staffing minimum of 3.20 hours of direct nursing care per resident were not met on the above dates.
| | Plan of Correction - To be completed: 01/10/2025
Admin and DON will conduct random audits of resident charts, during those days identified as having fallen below required minimum direct care, to ensure no negative outcomes in care.
Scheduler will be reeducated on required staffing for minimum direct care hours per resident.
The Admin will conduct a random audit weekly to ensure facility is compliant with staffing ratios. Audit will be for x3 weeks.
And monthly audit x4 months.
Results will be reported to QAPI.
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