(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 facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.87 hours of direct resident care for each resident.
Findings include:
A review of facility nurse staffing data, including deployment sheets for the week of December 18, 2023, through December 24, 2023, and for January 9, 2024, through January 15, 2024, the facility's 24 hour daily nurse staffing nurse staffing was below 2.87 hrs per resident on the following days:
January 9, 2024, nursing hours of direct resident care for each resident was 2.72 January 10, 2024, nursing hours of direct resident care for each resident was 2.61 January 11, 2024, nursing hours of direct resident care for each resident was 2.73 January 12, 2024, nursing hours of direct resident care for each resident was 2.80 January 13, 2024, nursing hours of direct resident care for each resident was 2.85 January 15, 2024, nursing hours of direct resident care for each resident was 2.75
Interview with the Administrator on January 16, 2024, at 12:45 p.m. confirmed the nursing hours indicated above.
| | Plan of Correction - To be completed: 02/04/2024
1. The facility cannot retroactively correct the minimum direct resident care hours on the one identified date.
2. The facility is focusing on retention and recruitment of direct care staff through efforts of the Staffing Committee.
3. To prevent this from recurring, The Scheduler and Nursing Supervisors educated by the NHA/Designee regarding the new direct resident care hours.
To prevent this from recurring, the facility to include census management to coincide with staffing levels
4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of direct care workers hours 5x weekly x4 weeks then weekly x2.
5. Findings will be submitted to the QAPI committee for further recommendations.
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