Deficiency in Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, as observed during the Recertification Survey. The deficiency was identified when the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. The facility's policy, last reviewed in September 2024, mandates that nursing staff information, including the census, be posted daily at the beginning of each shift. However, during observations from March 2 to March 3, 2025, the posted information only included the facility name, date, resident census, and actual hours worked by nursing staff, omitting the total number of staff directly responsible for resident care. Interviews conducted on March 7, 2025, revealed a lack of awareness among staff regarding the requirement to include the total number of nursing staff in the postings. The Staffing Coordinator acknowledged knowing that the posting should include hours worked by LPNs, CNAs, and RNs, but admitted to not paying attention to the information as it was not their primary responsibility. Similarly, a Registered Nurse and the Director of Nursing were unaware of the requirement to include the total number of staff giving direct care. The Director of Nursing admitted to not realizing the guidelines had changed, and the Administrator also confirmed their lack of awareness regarding the need to include the total number of staff providing direct care.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 The Nurse supervisors were immediately counseled on the proper requirements for the nurse staff posting. The facility immediately updated and posted the nurse staffing posting as required with the total amount of nurse staff hours, people and the census. The posting will be updated every shift. Element #2 The Director of Nursing reviewed the updated nurse staff posting to ensure it has all the required posting elements. The Director of Nursing educated all RN supervisors and the staffing coordinator of the required information needed on the daily nurse staffing posting. Element #3 The policy and procedure for the nurse staff postings will be updated to include the total amount of nurse staff hours, people and the census. The posting will be updated every shift. The Director of Nursing will educate all RN supervisors and the staffing coordinator of the updated policy. Element #4 An audit tool will be developed by the Director of Nursing to monitor the nurse staff posting. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25