Inaccurate Nurse Staffing Data Posting
Penalty
Summary
Mount Carmel Senior Living Community was found to be non-compliant with the requirements for posting nurse staffing information as per 42 CFR Part 483, Subpart B. During an observation on January 2, 2024, it was noted that the facility's posted nurse staffing data inaccurately reflected the number of nurse aides working the dayshift. The posted information indicated that 11 nurse aides were on duty, while only 10 were actually present. Additionally, the posted nurse aide hours for the dayshift were listed as 88 hours, but the facility's schedule showed only 70 actual hours worked. The discrepancy in the posted nurse staffing data was confirmed through an interview with the Director of Nursing on the same day. This failure to accurately post nurse staffing information is a violation of the federal regulation that requires facilities to maintain and display accurate daily nurse staffing data. The facility's inability to ensure the accuracy of this information was a key factor leading to the deficiency cited in the survey report.
Plan Of Correction
The error in the Staff Posting was corrected at the time of Survey. The daily Staff Posting will be reviewed for accuracy by the DON/Designee. Staff responsible for completing the Staff Posting will be educated regarding its completion and the importance of its accuracy. Random audits of the Staff Posting will be conducted by the DON/Designee weekly for 4 weeks and monthly for 2 months. Results of the audits will be reviewed at the monthly QAPI meeting.