(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 staffing documents and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period be a required minimum of 3.20 hours of direct care for each resident for three of seven days reviewed (December 7, 8, and 9, 2024).
Findings Include:
A review of facility-provided staffing information dated December 3, 2024 - December 9, 2024, revealed that the facility provided only 2.84 hours of direct care for each resident on December 7, 2024; 3.13 hours on December 8, 2024; and 3.06 hours on December 9, 2024.
An interview with the Nursing Home Administrator on December 10, 2024, at 9:47 AM, revealed the facility was not meeting the required minimum hours.
| | Plan of Correction - To be completed: 01/23/2025
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 will be educated on the 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. Results will be taken to the QAPI for review and revision as needed.
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