Failure to Properly Post and Record Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. Observations revealed that the daily nurse staffing data sheets for both Faith's Terrace and Love's Garden were posted on bulletin boards facing the nurse's station, making them inaccessible and not visible to residents or visitors passing by. The staffing data sheets were placed alongside other staff-only postings, such as on-call schedules and thank-you cards, further indicating that the information was intended for staff use rather than public access. During interviews, a CNA confirmed that the staffing data sheets were only posted where staff could see them and not where residents or visitors could access them. A review of historic daily nurse staffing data sheets showed that the facility did not consistently record the daily resident census or the actual hours worked by nursing staff by category. Instead, the sheets listed only the scheduled hours and staff names, with inaccuracies such as all nurse hours being entered under the RN category, even when most scheduled nurses were LPNs. The Nursing Home Administrator acknowledged that census numbers and actual working hours were not always recorded on the daily nurse staffing data sheets, and that he kept track of actual hours worked separately.
Plan Of Correction
1. No residents were negatively impacted by this deficient practice. 2. Clear wall paper holders were purchased and mounted in a location on the unit consistent with this requirement and visibility. 3. The Staffing Coordinator was educated on Posted Nurse Staffing Information by the NHA and its requirements including posting the total number of hours worked in real time. The Staffing Coordinator was educated on posting staffing sheets with documented census and updating hours worked upon shift change by the NHA. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of posting nurse staff information including the number of actual hours worked. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.