Walker Rehabilitation Center, Inc

Penalty

Inspection fine: $235,127

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's former Administrator, ADM #5, failed to provide adequate oversight to ensure the implementation of the facility's abuse policies and did not conduct thorough investigations of abuse allegations. This failure was identified through interviews, record reviews, and a review of the facility's policies. The Administrator's lack of action in ensuring that abuse allegations were thoroughly investigated and that appropriate corrective actions were taken was likely to result in further abuse and serious harm to residents. The deficiency was cited under 483.70 Administration at F 835-Administration. Interviews revealed that there was confusion regarding the role of the abuse coordinator, with ADM #5 initially being told that the Director of Nursing (DON) was the coordinator, but later informed that it was his responsibility. ADM #5 admitted to not recalling interviewing other residents or staff during abuse investigations, which is a critical step in identifying unreported concerns. The DON stated that she was not trained on abuse investigations and only observed the previous DON completing incident reports. Additionally, there were missing five-day reports for certain residents, which were the responsibility of ADM #5 to submit to the State Agency. The Director of Operations (DO) confirmed that the Administrator was always the designated abuse coordinator and was responsible for the five-day reports. However, ADM #5 received very limited training from the DO, who only spent one day at the facility with him and provided a checklist that was reportedly missing from his folder. This lack of training and oversight contributed to the failure in implementing the facility's abuse policies and conducting thorough investigations, affecting all residents in the facility.

Removal Plan

• The facility's Administrator resigned, and the new Administrator was hired.
• The Director of Operations trained the new administrator on the abuse policy.
• The Director of Operations provided one on one in-service education to the Administrator regarding the abuse policy being implemented and including conducting thorough investigations, collecting and retaining witness statements to determine a clear time of occurrence of events to ensure all staff respond appropriately and preserve all evidence such as videos of the incidents as applicable.
• The facility's abuse policy was discussed in the QAPI Committee Meeting with the Administrator understanding the responsibilities regarding the policy being implemented.
• Abuse in-services were held for all staff in all departments including nursing, therapy department, dietary, environmental services, and management. 75 employees were in-serviced.

Penalty

Inspection fine: $235,127

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 governing body of the facility failed to provide adequate oversight to ensure that the facility's Abuse Coordinators, including the Administrator, were properly trained in conducting thorough investigations, identifying contributing factors, and taking corrective actions to prevent further abuse. This lack of oversight was evident as the facility's Abuse Policy did not include a process for coordination with the Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring that all allegations of abuse are thoroughly investigated and appropriate corrective actions are taken. Interviews revealed confusion regarding the designation of the abuse coordinator, with the Administrator initially being told that the Director of Nursing was the coordinator, only to later be informed that it was his responsibility. The Administrator reported receiving limited training from his supervisor, the Director of Operations, who confirmed that she had not provided physical proof of investigations and had not participated in QAPI meetings. This lack of training and oversight contributed to the facility's noncompliance with federal requirements, which was determined to have caused or was likely to cause serious harm to residents. The deficiency was identified during the investigation of several Facility Reported Incidents and complaints. The Director of Operations admitted to not personally overseeing the QAPI Committee's handling of reported incidents of abuse, further highlighting the lack of effective governance and oversight. This failure had the potential to affect all residents residing in the facility, as the necessary processes and training were not in place to prevent and address abuse effectively.

Removal Plan

• Administrator resigned and the new administrator was hired.
• All residents have the potential to be affected by the deficient practice. The owner is a member of the governing body. The Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and how to take corrective action to prevent further abuse.
• The Director of Operations trained the new administrator on the abuse policy on how to conduct a thorough investigation, how to identify contributing factors, and how to take corrective actions to prevent further abuse. The Director of Operations updated the abuse policy to include the process for coordination within the QAPI program.
• Facility abuse policy was discussed in QAPI meeting. Actions taken by the QAPI committee include the 24-hour report book and 24-hour report being discussed in detail each morning during the morning meeting.
• The following personnel attended the QAPI meeting: RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, Medical Director.

Penalty

Inspection fine: $235,127

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's Quality Assurance and Performance Improvement (QAPI) committee failed to thoroughly review and address allegations of abuse that occurred on multiple occasions, specifically on 07/08/2023, 07/09/2023, 09/06/2023, and 05/10/2024. These incidents involved several residents and were not adequately analyzed to identify causal factors or to implement corrective actions to prevent future occurrences. The QAPI committee did not ensure that the facility's abuse policy was fully implemented, which includes identifying, stopping, and reporting abuse, as well as conducting thorough investigations. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that the QAPI meetings did not include discussions about the specific incidents of abuse. The DON admitted that the incidents involving certain residents were not discussed in any QAPI meetings, and the Administrator confirmed that while the number of abuse incidents was recorded, they were not reviewed or discussed in detail. This lack of discussion and analysis prevented the facility from addressing the culture and behavior of staff that led to the abuse. The Director of Operations, who was responsible for day-to-day operations, also acknowledged that she had not participated in QAPI meetings and expected them to occur monthly. She agreed that allegations of abuse should be discussed during these meetings to conduct root cause analysis. The failure to review and discuss these incidents in QAPI meetings resulted in the facility's noncompliance with regulatory requirements, which was determined to have caused or was likely to cause serious harm to residents.

Removal Plan

• Administrator resigned and the new administrator hired.
• Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse.
• The Director of Operations in-serviced the new administrator on QAPI program and all the elements related to abuse including screening, training, prevention, identification, investigation, protection, reporting/response, and QAPI.
• The administrator trained following employees who attended QAPI committee meeting include RN supervisor, medical records, director of rehab, director of nursing, infection preventionist/restorative nurse, environmental services, director of operations, and corporate human resources director on QAPI program and all the elements related to abuse including screening, training, prevention, identification, investigation, protection, reporting/response, and QAPI.
• All abuse investigations were reviewed by the Administrator to ensure all allegations were identified by staff, residents were immediately protected, allegation reports per policy, investigations were completed appropriately, had appropriate witness statements collected, all causal factors were identified, and appropriate corrective action was taken.
• Employees who failed to report are no longer employed with the company and the residents are not in the facility at this time.
• The Director of Operations provided 1-on-1 in-service to Administrator and DON regarding conducting QAPI meeting.
• Monthly QAPI meetings were reviewed to ensure no other residents were affected. Reviewed to make sure nothing was missed in QAPI.
• The Ad Hoc QAPI meeting was completed. QAPI committee was informed and the plan was made that one member of the corporate team will be included in all meetings to ensure allegations of abuse and monthly QAPI meeting to ensure all causal factors are addressed.
• The causal factors will be identified through the root cause analysis using the five Why's method. QAPI team will need to be educated on conducting root cause analysis.
• QAPI meeting held to develop and implement a process to ensure all substantiated allegations of abuse are reviewed and analyzed to ensure the appropriate corrective actions is taken to address all contributing factors of abuse.
• The administrator will be responsible for bringing all allegations of abuse to the QAPI meeting utilizing root cause analysis and the five why's method to ensure all casual factors have been addressed.

Penalty

Inspection fine: $235,127

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 protect residents from abuse by staff and other residents, resulting in multiple incidents of verbal, physical, and mental abuse. One incident involved a Certified Nursing Assistant (CNA) verbally abusing a resident by cursing and slamming a bathroom door, causing the resident to cry. Another incident involved the same CNA withholding a lunch tray from a resident, leading to feelings of humiliation and dehumanization. Witnesses, including other CNAs and a Dietary Manager, failed to intervene or report the abuse immediately. In another case, a resident was physically and mentally abused by a CNA who hit the resident with a package of wipes, restrained the resident's arm, and threatened to break it. A witness to this abuse did not intervene or report it until the following day. Additionally, a resident was roughly handled by a CNA who jerked and pulled the resident in a wheelchair, causing the resident to become tearful and upset. This incident was witnessed by a Dietary Aid who reported the behavior. Further incidents included a resident being slapped by another resident in a dining area, and a CNA yelling at a resident to dress themselves despite the resident's care plan requiring assistance. These actions were witnessed by staff who either failed to intervene or report the incidents promptly. The facility's policy on abuse prevention was not effectively implemented, leading to these deficiencies.

Removal Plan

• Verbal abuse was submitted to the state. The allegation was that CNA #8 verbally abused RI #5. C.N.A #8 was placed on administrative leave and terminated. RI #5 had a skin evaluation. RI #5 was assessed with no indication of emotional distress.
• Verbal abuse was submitted to the state. The allegation was that CNA #8 verbally and mentally abused RI #98. C.N.A #8 was placed on administrative leave and terminated. No documentation of any assessment or notifications. RI #98 expired.
• Physical and mental abuse submitted to state. The allegation was CNA #8 physically and mentally abusing RI #99. The incident was witnessed by CNA #22. C.N.A #9 was terminated. Skin evaluation performed, DON entered a progress note concerning the event. Medical Director was notified.
• Physical and mental abuse submitted to state. CNA #24 was placed on administrative leave and terminated. Skin evaluation performed, Medical Director, family and police department was notified.
• Performed an audit by asking every resident with a BIMS of 8 or higher if they had been a victim of abuse or witnessed suspected abuse that has not been reported and/or investigated to ensure no other residents were affected by the deficient practice. Responsible parties were contacted for all residents with a BIMS' of 7 or less. Forty-three residents reviewed. Zero were found to be affected.
• Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse.
• Director of Operations trained the Administrator, DON and RN Supervisor ensuring facility's abuse policies are implemented on how to conduct a thorough investigation, identifying contributing factors and take corrective action to prevent further abuse. Ensure during investigations all witness statements are collected, and the Administrator is the abuse coordinator and is responsible for all reporting of allegations and ensuring completion of the investigation.

Penalty

Inspection fine: $235,127

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 implement its policies and protocols to immediately intervene and protect residents from abuse, as well as to report the abuse promptly. On one occasion, two CNAs witnessed another CNA intentionally withholding a meal tray from a resident for disciplinary reasons. Despite witnessing this act, the CNAs did not intervene to protect the resident or report the abuse immediately to the administration. The abuse was not reported until the following day, allowing the abusive CNA to continue working in the facility. In another incident, a CNA witnessed a colleague physically and verbally abusing a resident by hitting them with a package of wipes and threatening to break their arm. The witnessing CNA failed to intervene or report the abuse immediately, allowing the abusive CNA to continue working and having access to residents. The abuse was only reported the next day, and the resident was later found to have a bruise on their wrist. The facility's investigative files lacked documentation of witness statements or any information about the failure of staff to stop the abuse, protect the residents, and report the abuse immediately. Interviews with the former administrator and DON revealed confusion and inadequate training regarding the investigation and reporting of abuse incidents. The facility's noncompliance with abuse prevention policies was determined to have caused or was likely to cause serious harm to residents.

Removal Plan

• Verbal abuse was submitted to the state. C.N.A #8 was placed on administrative leave and terminated.
• Physical and mental abuse submitted to state. C.N.A#9 was terminated. Skin evaluation performed, DON entered a progress note concerning the event. The Medical Director was notified.
• All abuse investigations were reviewed by the Administrator to ensure all allegations were identified by staff, residents were immediately protected, allegation reports per policy, investigations were completed appropriately, had appropriate witness statements collected, all causal factors were identified, and appropriate corrective action was taken.
• The Administrator was in-serviced conducting a thorough investigation.
• Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors, and take corrective action to prevent further abuse.
• Director of Operations trained the Administrator and DON.
• Director of Operations trained the Administrator, DON and RN Supervisor ensuring facility's abuse policies are implemented on how to conduct a thorough investigation, identifying contributing factors and take corrective action to prevent further abuse. Ensure during investigations all witness statements are collected, and the Administrator is the abuse coordinator and is responsible for all reporting of allegations and ensuring completion of the investigation.
• Abuse in-services were held by the DON, by the Administrator, and by RN Supervisor. All staff in all departments including nursing, therapy department, dietary, environmental services, management. 75 employees were in-serviced.
• Staff were educated on what constituted abuse including depriving goods/services for disciplinary reasons, when abuse is witnessed or suspected you are to PROTECT THE RESIDENT!!!, what should be reported (ANY suspected abuse), when to report, and to whom to report. Also, training included how to safely provide care for residents who may be agitated or resistive to care and that the facility has zero tolerance for abuse.
• Director of Clinical Services trained the Director of Operations the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse. If any staff do not attend the in-service for whatever reason, the Administrator and DON will train department heads to complete the in-service with the employees prior to returning to their next scheduled shift.
• Ad hoc QAPI meeting was attended by the RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, Medical Director to discuss abuse recognition, reporting, and prevention. Also to ensure the Administrator understands responsibility to ensure all facility policies are implemented.
• Corporate will sign off on facility reportable for compliance, and on facility abuse policy/QAPI policy are implemented/conducted according to the policy on abuse.
• The abuse policy was updated to include the use of root cause analysis, to identify, evaluate, monitor, and improve facility systems and processes that support the delivery of caring services. The updated policy was approved by the governing body.

Penalty

Inspection fine: $235,127

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 conduct thorough investigations into multiple incidents of abuse involving residents and staff members. On one occasion, a Certified Nursing Assistant (CNA) verbally and mentally abused a resident by yelling and cursing at them, and another resident was denied a lunch tray, causing distress. Witnesses to these incidents, including other staff members, failed to intervene or report the abuse immediately. The facility's investigation did not include obtaining statements from all witnesses or identifying contributing factors to prevent further abuse. In another incident, a CNA physically and mentally abused a resident by hitting them with a package of wipes and threatening to break their arm. A staff member witnessed the abuse but did not intervene or report it. The facility's investigation lacked a comprehensive review, including interviews with other residents who might have had knowledge of unreported abuse. Additionally, a resident was physically abused by a CNA who handled them roughly in a wheelchair, causing the resident to become tearful and upset. The facility did not conduct interviews with other residents to determine if there were additional instances of abuse. The investigations were incomplete, lacking necessary documentation, witness statements, and timely reporting to the appropriate authorities.

Removal Plan

• CNA #8 was placed on administrative leave and terminated.
• CNA #9 was terminated.
• CNA #24 was terminated.
• Director of Clinical Services reviewed all abuse investigations.
• New administrator hired.
• Director of Operations provided an in-service to new administrator and DON regarding abuse policy implemented and including conducting thorough investigations, collecting and retaining witness statements to determine a clear time of occurrence of events to ensure all staff respond appropriately per the policy, preserving evidence such as videos of the incidents as applicable, identifying all causal factors, and implementing the appropriate corrective action(s).
• Administrator reviewed all incidents of abuse, neglect, and misappropriation reported to the state agency.
• QAPI meeting was attended by: RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Director, Director of Operations, Administrator and Medical Director to discuss the abuse prevention policy.
• Director of Operations completed QAPI meeting with the Administrator on understanding administrator's responsibility regarding policy being implemented and followed and expectations for conducting a thorough investigation including identification of all causal factors and implementing corrective action(s).
• Director of Operations will sign off on reportable investigations to ensure compliance with abuse/ and QAPI policy.
• Administrator will email the DO the allegation when reported and email the completed investigation summary.
• Administrator, DON and DO and Director of Clinical Services will do a conference call before submitting the five-day summary to state.

Penalty

Inspection fine: $235,127

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 staff reported abuse immediately to the Administrator, which resulted in a delay in reporting allegations of abuse to the State Agency within the required two-hour timeframe. In one instance, a resident was verbally and mentally abused by a CNA, witnessed by other staff members, but the incident was not reported to the Administrator until the following day. This delay in reporting prevented timely intervention and protection for the resident. In another case, a resident was verbally and physically abused by a CNA, with the incident being witnessed by another CNA who failed to report it until the next day. This delay in reporting also hindered the facility's ability to take immediate corrective actions to protect the resident from further potential abuse. The facility's noncompliance with reporting requirements was determined to have caused, or was likely to cause, serious harm to residents. The facility's policy on abuse prevention required immediate notification of the Administrator or designee of any allegations or suspicions of abuse, and completion of abuse reporting to the State Agency within two hours. However, in both cases, the facility did not adhere to this policy, resulting in a citation for Immediate Jeopardy due to the potential for serious injury, harm, impairment, or death to residents.

Removal Plan

• Verbal abuse involving CNA #8 was submitted to the state. CNA #8 was placed on administrative leave and terminated.
• Physical and mental abuse submitted to the state involving CNA #9 as perpetrator. CNA #9 was terminated.
• An audit was performed by asking every resident with a BIMS of 8 or higher if they had been a victim of abuse or witnessed suspected abuse that has not been reported and/or investigated. Forty-three residents reviewed. Zero was found to be affected.
• Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, identify contributing factors, and take corrective action to prevent further abuse.
• Abuse in-services were held for all staff in all departments including nursing, therapy department, dietary, environmental services, and management. 75 employees were in-serviced.
• Licensed nurses and CNAs will document any unusual observations in the 24-hour report book located at the nurse's desk and call the Administrator immediately if abuse is suspected or witnessed.
• Actions taken by the QAPI committee include the 24-hour report book and 24-hour report being discussed in detail each morning during the morning meeting.
• A QAPI meeting was held to discuss the abuse prevention policy and above-mentioned cases with personnel including RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, and Medical Director.

Penalty

Inspection fine: $235,127

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 adhere to its policy on cleaning dishes and dish machines, leading to wet nesting of plate domes and trays. Observations revealed that clean trays and domes were stacked on top of each other immediately after coming out of the dishwasher, without allowing them to air dry as required by the facility's policy. This resulted in several trays and domes having water in them, which was confirmed by a dietary aide who admitted to not knowing the policy on wet nesting and not having received training on the matter. The dietary manager acknowledged the lack of training and the importance of ensuring that domes and trays are dry to prevent bacterial growth. Additionally, the facility did not comply with its policy on taking and recording food temperatures. During a lunch meal service, a cook/dietary aide took temperatures of various food items but failed to document them as required. The aide admitted to not remembering the temperatures and not writing them down immediately, as well as not knowing the facility's policy on recording food temperatures. The dietary manager confirmed that all food items on the tray line should have their temperatures taken and recorded immediately.

Penalty

Inspection fine: $235,127

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 Certified Medication Aides (CMAs) did not administer subcutaneous insulin injections to residents, which is outside their scope of practice. This deficiency affected seven of the sixteen sampled residents receiving medications, with insulin being administered by four of the five Medication Assistants, Certified (MACs) involved. The facility's job responsibilities for CMAs clearly state that they are not permitted to administer injectable medications, except for specific exceptions like premeasured auto-injectable medications for anaphylaxis, vaccines, and opioid-related drug overdoses. Despite this, insulin was administered multiple times to several residents by MACs #10, #11, #12, and #13 from May 2023 through October 2023. Interviews with the MACs and nursing staff revealed that the MACs were instructed to administer insulin, although it was not within their scope of practice. MAC #13 admitted to administering insulin until October 2023, while MAC #18 refused to do so and reported the issue to the Director of Nursing (DON). The RN Supervisor and the current DON confirmed that MACs were not trained to recognize signs of hypoglycemia or hyperglycemia and that insulin administration was not part of their training or scope of practice. The former DON stated that the practice was already in place when she was hired, and it was instructed by the corporate nurse at the time. The current DON, upon discovering the issue, contacted the Alabama Board of Nursing, which confirmed that MACs should not administer insulin, leading to the cessation of this practice.

Penalty

Inspection fine: $235,127

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 maintain a safe, clean, comfortable, and homelike environment for several residents, as observed during a survey. Specifically, the facility did not ensure that window screens were present on the windows of multiple residents' rooms, including those of Resident Identifiers (RI) #8, #10, #11, #12, #19, and #44. Additionally, there were holes in the glass windowpanes in the rooms of RI #10, #11, and #44, and paint was observed peeling off the ceiling in these rooms. The shared bathroom for these residents had a stained floor, and the call light wires were intertwined with plumbing under the sink, which was not in line with the facility's policy for a homelike environment. Observations revealed that the windows in the affected rooms had missing or broken screens, and some windowpanes had holes, allowing cold air to enter the rooms. This was corroborated by residents' complaints of feeling cold, as noted by RI #44 and RI #10. The Maintenance Director (MTD) acknowledged these issues, stating that the absence of window screens and the presence of holes in the windowpanes posed risks such as bugs entering the building and potential harm to residents. The MTD also noted that the peeling paint and missing baseboards did not contribute to a homelike environment. Interviews with the MTD and the current Administrator (ADM) #1 confirmed that the facility was aware of these deficiencies. The MTD admitted to being responsible for the upkeep of the windows and acknowledged that the facility should be a clean, homelike environment. ADM #1 stated that repairs should be timely to ensure a homelike environment, indicating an awareness of the need for improvements. However, the report does not mention any corrective actions taken to address these deficiencies.

Penalty

Inspection fine: $235,127

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 the required data was included on the staff posting form, specifically the census and the number of staff working along with the actual hours worked for all nursing staff on four out of five days during the survey. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' required that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care be posted. The policy also required that the staffing information include the facility name, date, resident census, shift schedule, and actual hours worked for each category and type of nursing staff. During the survey, it was observed that the staffing sheets posted at the nurses' station lacked documentation of the census and total hours worked for the first and second shifts on multiple days. Interviews with the Director of Nurses (DON) revealed that the facility did not follow its policy, as the staffing sheets were not posted within the required timeframe, and essential information such as the census and total hours worked was missing. The DON acknowledged the importance of having an accurate staff count for emergency situations and confirmed that the policy was not adhered to, resulting in a lack of accurate staffing information.