Deficiency in Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, specifically the actual number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care. This deficiency was identified during the Recertification Survey conducted from January 2, 2025, to January 8, 2025. The facility's policy, last revised in October 2022, mandates that staffing postings should include the facility name, current date, resident census, facility-specific shift schedule, and the number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse's Aides. However, during multiple observations from January 2 to January 7, 2025, the posted nurse staffing information in the lobby only included the facility name, current date, number of nursing staff working, and resident census, omitting the actual hours worked. Interviews with the Staffing Coordinator and the Director of Nursing revealed a lack of awareness and adherence to the requirement to list actual hours worked by nursing staff.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Element 1: The staffing template was corrected to reflect work hours. Updated sheet posted. Element 2: All residents had potential to be affected by the deficient practice. Element 3: The policy & procedure for STAFFING – POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION was reviewed and no revisions were necessary. HR was inserviced on STAFFING – POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION policy. An audit tool was developed. Weekly rounds x4, Monthly x3 to ensure proper staffing posting. Element 4: Audit to be done by Administrator/designee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA committee monthly x3. Responsible party Administrator/designee.