Inaccurate Nurse Staffing Records and Missing Census Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information included the current census and the actual hours worked by nursing staff, specifically Certified Nursing Assistants (CNAs). On multiple occasions, the Daily Nurse Staffing records did not accurately reflect the number of CNAs working on specific shifts. For instance, on February 15, 2025, the staffing records indicated that 7 CNAs worked the 7:00 AM to 3:30 PM shift, while assignment sheets showed 8 CNAs were present. Similarly, discrepancies were noted on February 16 and February 18, 2025, where the documented staffing did not match the actual number of CNAs working or the hours worked. Additionally, the facility failed to document the census on these dates, which is a required component of the daily staffing posting. The Administrator acknowledged that the Staffing Coordinator was responsible for posting the Daily Nurse Staffing at the beginning of each day. However, the Administrator admitted that the postings did not account for unforeseen changes to the schedule and did not reflect the actual hours worked by the nursing staff. Furthermore, the postings did not include the facility's daily census, which is a requirement. This lack of accurate and complete staffing information was observed during the recertification survey conducted from February 12 to February 19, 2025, and was a violation of the regulatory requirements.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No residents identified as having been affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents residing within the nursing facility have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Nursing or Designee will develop a procedure to ensure accuracy of Posted Nursing Staffing Information by 3/20/25. ò Director of Nursing or designee will in-service Staffing Coordinator on Posted Nursing Staffing Information to ensure current census and total actual hours worked by nursing staff are included by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Administrator or designee will audit 20% of Posted Nursing Staffing Information. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing