(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 interviews 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 20 of 21 days (12/10/23, 12/11/23, 12/12/23, 12/13/23, 12/15/23, 12/16/23, 12/17/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/23/23, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, and 12/30/23).
Findings include:
Nursing time schedules for the time period of 9/17/23 through 9/23/23, and 10/1/23 through 10/14/23, 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 dates:
-12/10/23, Census 146. PPD 2.84 -12/11/23, Census 146. PPD 2.71 -12/12/23, Census 150. PPD 2.79 -12/13/23, Census 149. PPD 2.56. -12/15/23, Census 151. PPD 2.61. -12/16/23, Census 151. PPD 2.62. -12/17/23, Census 150. PPD 2.49. -12/18/23, Census 150. PPD 2.49. -12/19/23, Census 150. PPD 2.76. -12/20/23, Census 148. PPD 2.75. -12/21/23, Census 155. PPD 2.60. -12/22/23, Census 155. PPD 2.71. -12/23/23, Census 155. PPD 2.18 -12/24/23, Census 155. PPD 2.04 -12/25/23, Census 155. PPD 2.16. -12/26/23, Census 155. PPD 2.34. -12/27/23, Census 154. PPD 2.61. -12/28/23, Census 154. PPD 2.66. -12/29/23, Census 157. PPD 2.39. -12/30/23, Census 155. PPD 2.43.
During an interview on 1/12/24, at 12:15 p.m. the Nursing Home Administrator confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 20 of 21 days.
| | Plan of Correction - To be completed: 02/15/2024
There were no adverse effects to the residents in the center as a result of the HPPD of less than 2.87.
The Administrator, Director of Nursing, and Scheduler will be re-educated on the state requirement for nursing hours by the Nurse Professional Educator.
Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the 2.87 minimum then the facility will reach out to current staff and staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.
Audits of HHPD will be completed weekly x4 by the NHA/designee to ensure the state HPPD minimums are met. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
PRINTED: 7/20/2023
will be completed weekly x4 by the NHA/designee to ensure HPPD and staff ratios meets the state minimums. Results of the audits will be forwarded to the center QAPI committee for review and recomme There were no adverse effects to the residents in the center as a result of the HPPD of less then 2.87 and decreased staff ratios on July 2, 3, 4, 5, & 6
The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for nursing hours and staff ratios by the Quality Clinical Consultant/designee. Staffing meetings will be held 5 days a week to review HPPD and staff ratios from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the 2.87 minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.
Audits of HHPD and staffing ratios State Form
will be completed weekly x4 by the NHA/designee to ensure HPPD and staff ratios meets the state minimums. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
will be completed weekly x4 by the NHA/designee to ensure HPPD and staff ratios meets the state minimums. Results of the audits will be forwarded to the center QAPI committee for review and recomme
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