Failure to Post Night Shift Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual nursing hours for the night shift (NOC, 11PM to 7:30 AM) from March 2, 2025, to March 7, 2025, in both the Lobby and South Station. This omission was identified through interviews and record review, where it was confirmed that the required nurse staffing information, including the actual hours worked by RNs, LPNs, and CNAs, as well as the resident census, was not posted for the NOC shift as mandated by federal regulations. During interviews, the Director of Staff Development (DSD) acknowledged that the NOC shift hours were not posted and stated that this would prevent staff, family members, visitors, and residents from knowing the staffing levels for that shift. The staff member responsible for posting the information also confirmed that the NOC shift hours were not posted and indicated a need for training on the process. Review of the facility's policy confirmed that posting direct care daily staffing numbers for every shift is required.
Plan Of Correction
F732: Posted Nurse Staffing Informing CORRECTIVE ACTION On 3/7/2025, the scheduler posted the daily staffing data in the lobby and south station. OTHER RESIDENTS AFFECTED IDENTIFICATION No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES The DSD/designee will check the nurse staffing posting daily to verify that the posting is current and will report findings to the daily (Monday to Friday) standup meeting. On 3/14/2025, the DSD provided in-service to staff regarding the importance of updating the nurse staffing posting within 2 hours of the beginning of the shift. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. 3/28/2025