(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 a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for eight of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from January 10, 2024, to January 31, 2024, revealed the following total nursing care hours below minimum requirements:
Friday, January 12, 2024, 2.74 care hours per resident Saturday, January 13, 2024, 2.75 care hours per resident Monday, January 15, 2024, 2.80 care hours per resident Tuesday, January 16, 2024, 2.79 care hours per resident Wednesday, January 17, 2024, 2.77 care hours per resident Sunday, January 21, 2024, 2.86 care hours per resident Monday, January 22, 2024, 2.79 care hours per resident Tuesday, January 23, 2024, 2.80 care hours per resident
In an interview on February 1, 2024, at 1:50 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing care hours.
| | Plan of Correction - To be completed: 02/26/2024
1. Facility cannot retroactively correct the PPD hours below minimum requirements 2. NHA, DON, and staffing scheduler will have daily meetings to ensure PPD hours are above minimum required 2.87. Facility will continue to hire and utilize agency staff for open shifts. 3. NHA, or designee, will educate staffing scheduler and DON on maintaining at least the minimum required PPD of 2.87. 4. NHA, or designee, will perform audits with DON and staffing scheduler to ensure PPD hours are at, or above state minimum required hours. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
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