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F0732
C

Inaccurate Daily Nurse Staffing Sheets

Fletcher, North Carolina Survey Completed on 06-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff who worked for all 16 days reviewed. The daily nurse staffing sheets were intended to specify the date, resident census, and the number and hours worked for RNs, LPNs, and CNAs for each shift. However, a comparison between the posted staffing sheets and the nursing staff time clock reports revealed multiple discrepancies in the recorded numbers of staff and hours worked across various shifts and dates. In several instances, the staffing sheets listed more staff than were actually present according to the time clock records, and in some cases, the staff categories and hours did not match at all. The discrepancies included differences in the number of RNs, LPNs, and NAs reported on the staffing sheets versus those recorded in the time clock system. For example, on certain shifts, the staffing sheets indicated the presence of RNs when none were recorded as working, or listed more NAs than were actually present. There were also instances where the resident census was not listed, and where the staff assignment schedule did not align with the posted staffing information. These inconsistencies were observed across all reviewed dates and shifts, affecting the accuracy of the facility's posted nurse staffing information. Interviews with facility staff revealed that the Scheduler, who was responsible for posting the daily staffing sheets, typically posted them in the morning and did not update them to reflect call-outs or schedule changes. The Scheduler was not aware that updates were required to ensure the posted information matched the actual staff present. The Administrator confirmed that the expectation was for the staffing sheets to be updated as needed to accurately reflect the nursing staff working each shift.

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