Failure to Post Nurse Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that the current resident census and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were posted in a prominent place, readily accessible to residents and visitors, on three of the six days reviewed during the recertification survey. From January 22 to January 24, the daily resident census and nurse staffing information were not visible in a prominent location. Interviews with the Director of Nursing and a Nurse Manager revealed that the staffing reports were typically placed on a table near the front desk security, but during an observation, the information was found obscured by other papers, making it not visible to residents or visitors. The Administrator acknowledged the issue and stated that the data would be relocated to a visible bulletin board at the lobby entrance.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice: The deficient practice was corrected immediately by installing a locked bulletin board in the lobby of the facility to publicly display the daily resident census and nurse staffing information. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above): All residents were affected by this deficient practice since the facility did not have the daily resident census and nurse staffing information in an area clearly visible to residents, patients, and families. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: The DON and/or designee will ensure that the daily resident census and nurse staffing information is posted daily on each shift. All RN Nursing Supervision and Nurse Managers will be in-serviced on policy for posting daily resident census and nurse staffing information by the DON and/or designee. All newly hired supervisors/nurse managers will be in-serviced at the time of hire. All nursing management staff will receive annual in-service on completing and posting of the daily census and nurse staffing information. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change): The Administrator and/or designee will audit the daily staffing and resident census posting daily for 2 weeks and then weekly for 1 month. Results of the audit will be reported to the QAPI committee monthly by the Administrator for 3 months for action as appropriate.