Failure to Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted and updated as required during a Recertification Survey. Observations on multiple occasions revealed that the daily nurse staffing information was not posted at the beginning of each shift. Additionally, the information was not updated to reflect staffing changes throughout the day, and the facility did not maintain records of the daily nurse staffing data for the required minimum of 18 months. Interviews with the Director of Human Resources and the Director of Nursing confirmed these deficiencies. The Director of Human Resources admitted that the staffing information was completed in the morning but not updated during the day or over the weekend. Furthermore, the facility was unable to provide any past daily nurse staffing information sheets when requested. The Director of Nursing acknowledged that the staffing information should be posted in an accessible area, updated for accuracy, and retained for record-keeping purposes.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. BIPA was immediately corrected. BIPAs will be placed with accurate information and saved in a binder. 2. All residents have the potential to be affected. BIPA will be placed with accurate information and saved in a binder. 3. Education was provided to the Administrator, Director of Nursing, nursing administration, and nursing staff on how to calculate the BIPA correctly. The facility will conduct weekly audit of BIPA to make sure it has correct information x 4 then monthly x 2 until corrected. The staffing coordinator or designee is responsible for the correction and monitoring.