Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data was complete and accurate, as required. During an unannounced visit, it was observed that the posted documents for nurse staffing, specifically the Census and Direct Care Services Hours Per Patient Day (DHPPD), only included projected (estimated) hours and did not have the actual direct care service hours, average patient census, actual DHPPD, or actual CNA hours filled in for the reviewed dates. The section of the form designated for actual hours was left blank, despite instructions that it must be completed at the end of each 24-hour patient day. Interviews with the Director of Staff Development (DSD) revealed that actual DHPPD hours were not calculated or posted daily because the DSD did not have access to payroll hours until the day after paydays, which occur twice a month. As a result, only projected staffing hours were posted, and actual staffing data was not made available to residents and the public on a daily basis as required. This omission was verified during both document review and staff interviews.