Failure to Properly Post Nursing Staff Information
Penalty
Summary
The facility failed to comply with statutory requirements for daily posting of nursing staff information. During observations, the posted staff list across from the nursing station included only names, without specifying titles such as licensed nurses or certified nursing assistants (CNAs). Additionally, the posting did not indicate room assignments for the four units, making it unclear which staff members were responsible for specific residents. Surveyors had to ask staff to determine which personnel were assigned to particular residents, and random residents questioned were unable to identify their assigned nurse by looking at the posted information. The Assistant Director of Nursing confirmed these findings during an interview.
Plan Of Correction
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator during staffing meetings will continue to ensure compliance with the requirement. On weekends, the Director of Nursing will verify with the Supervisor and monitor callouts for replacements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The missing staffing information such as titles and room assignments for the Certified Nursing Assistants and Licensed Nurses identified were corrected. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Meeting scheduled with the resident council on to review the posted assignments to ensure understanding. Random residents will be questioned on who their assigned nurses and the Certified Nursing Assistants are to ensure understanding. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nurse Managers and Licensed Nurses have been re-educated regarding posting nurse staffing information to include titles and room assignments. Weekly audits will be completed to ensure compliance times four weeks. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met.