Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information, including the total number of staff and total number of hours, was posted as required. Observations conducted from February 5 to February 11, 2025, revealed that this information was not displayed in the lobby or nursing unit, contrary to the facility's policy. The policy, last revised on January 2, 2025, mandates that nurse staffing information be readily available in a readable format in prominent places accessible to residents and visitors. Despite the daily schedule being posted in the lobby, the specific details of total staff and hours were not included. Interviews with facility staff highlighted a lack of awareness and oversight regarding the posting requirements. The Staffing Coordinator acknowledged that the detailed staffing information was attached to the schedule at the end of the day but not posted as required. The Director of Nursing admitted to not being aware that the information was not being posted and did not routinely check for compliance. Similarly, the Administrator stated that while they usually check the postings every morning, they had not done so since the survey began and were unaware of the missing information.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - The daily nurse staffing data was posted in a prominent place for residents and visitors to see in the facility’s lobby by front desk on 2/11/2025 and daily thereafter. - Facility Staffing Coordinator and Director of Nursing were educated on a policy “Posted Nurse Staffing Information” with an emphasis on posting in a prominent place readily accessible to residents and visitors on 2/11/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The Policy and Procedure titles “Posted Nurse Staffing Information” was reviewed and no revision is required. - Nursing Administration, Staffing Coordinator, RN Supervisors and RNs are being in-serviced on the above policy. - Director of Nursing is going to oversee daily nurse staffing data posting. - The audit tool was developed for monitoring compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - Twice a week for one quarter, Director of Nursing or designee, will randomly check 2 prominent locations to ensure the nurse staffing data is posted and is accurate. - Any outstanding findings will be addressed immediately and reported to the Administrator. - On a weekly basis Director of Nursing or designee will report the findings to the Administrator. - On a monthly basis Director of Nursing or designee will report findings to Administrator. - On a quarterly basis Director of Nursing or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Administrator.