Failure to Post Actual Nurse Staffing Hours: The facility posted nurse staffing sheets that listed staff counts and scheduled hours, but not the actual hours worked. Administrative staff stated the actual hours were recorded on a signed log kept in a lobby binder, but that log was not posted. The facility policy required nurse staffing information to be readily available and posted in a prominent, readable location.
Failure to Post Required Nurse Staffing Information: Surveyors observed the Daily Nurse Staffing Report posted with the names of nurses and aides on duty and the hours they worked, but it did not include the required breakdown of RN, LPN, CMA, and NA staffing by shift or the total actual hours worked per shift. Administrative staff verified the report should also show the number of staff for each shift and the facility census, consistent with the facility's staffing posting policy.
Incomplete Daily Staffing Postings: The facility failed to post accurate, publicly accessible staffing information on a daily basis. Review of Daily Staffing Sheets showed the facility name and actual hours worked were left blank, and an administrative staff member confirmed the omissions. The facility policy required the staffing form to include the facility name, current date, total number, and actual hours worked by RN, LPN, and CNA.
Incomplete Daily Nurse Staffing Postings: The facility’s posted staffing sheets were missing required information, including the census and the actual hours worked for RN, LPN, and CNA/CMA staff. Observation and record review showed the daily staffing forms for multiple shifts were not filled out completely, and facility staff acknowledged that all required areas should be completed each day.
Inaccurate Daily Nurse Staffing Sheet Posting: The facility failed to post accurate daily nurse staffing information, including the census. A staffing sheet posted behind the front desk listed a census of 71, while the census verified by Administrative Staff A was 67. The same outdated sheet remained posted the next day, and no current sheet was observed. Administrative Staff A stated the CSA updates the staffing sheets and that an incorrectly completed sheet would require education.
Failure to post and retain daily nurse staffing information. Observation showed no staffing sheet posted, and an AN stated the staffing information should be easily viewed. The facility also did not keep records of all daily nurse staffing postings for the required 18 months, despite policy stating the information must be readily available to residents, staff, and visitors.
Inaccurate daily nurse staffing information was posted near the admin offices, with a staffing sheet displayed under the wrong date before being updated later that morning. The ADON reported staffing oversight was split between two people, a charge nurse would post the sheet if a staffing coordinator was unavailable, and the sheet was expected to be updated daily. The facility also reported it did not have 18 months of staffing sheets and could only provide records from late December forward, despite policy requiring daily posting of direct care staffing data.
The facility failed to ensure daily nurse staffing data was posted and that the posted staffing sheets included required information. Review of the staffing postings showed an outdated date on the sheet and missing daily census information on multiple posted forms. An Administrative Nurse stated an Administrative Staff member was responsible for ensuring the sheets were posted, and that the receptionist posted them on weekends using the forms provided.
Incomplete Nurse Staffing Posting: The facility posted a daily nursing staffing sheet near the nursing station that listed employee numbers and hours but did not include the facility name or the daily nursing staff total hours. An Administrative Nurse stated he had not noticed the missing totals and was unaware the facility name had to be included on the daily staffing form.
Inaccurate posted nurse staffing information was observed near the nursing station. Review of staffing sheets showed missing scheduled hours on multiple sheets, and the resident census was absent on some sheets. An Administrative Nurse stated the unit floor nurse completed and posted the sheet before the next shift, and the facility policy required the DON or designee to ensure the daily RN, LPN, and CNA staffing schedule was posted at the entrance to each household.
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