Inaccurate Daily Nurse Staffing Sheets: The facility failed to accurately post licensed nursing hours on daily staffing sheets reviewed across multiple shifts. The posted totals for RNs and LPNs did not match the actual scheduled hours, and the Staffing Coordinator stated she calculated hours by counting staff in the building and multiplying by 12 rather than using each nurse’s actual hours worked. The Administrator stated he expected the staffing sheet to accurately reflect current staffing.
The facility failed to post accurate daily nurse staffing data, with posted RN, LPN, and NA counts not matching the staffing schedule across multiple shifts. Record review showed repeated discrepancies in both licensed and non-licensed staffing totals, and interviews revealed the previous Scheduler had not been adjusting the postings when staffing changes occurred. The DON had only recently taken over scheduling after the previous Scheduler left, and the Administrator was unsure why the postings were not corrected.
Failure to Post Updated Daily Nurse Staffing Sheet: The facility did not post an updated daily nurse staffing sheet for residents and visitors on one surveyed day. The sheet near the main entrance remained dated from the prior Friday and did not reflect the current date, census, or staffing information. The Scheduler said weekend staff were responsible for updating and posting the sheet, while an RN supervisor reported she updated it but became busy with resident care and did not post it. The DON confirmed the sheet was not updated because the weekend supervisor became busy.
Inaccurate skilled unit census was posted on the nurse staffing sheets for multiple days. The Scheduler said she counted residents from both the skilled unit and LTC unit together and entered the same total for all shifts, rather than separating the census by unit. The DON stated the skilled unit and LTC census should be posted separately, and the Administrator said the process failed because the Scheduler had received inaccurate training.
Daily nurse staffing sheets were posted with a single Licensed Nursing Staff column that did not separately total RN and LPN hours or counts, affecting all 33 days reviewed. The Staffing Coordinator, Nurse Supervisor, DON, and Administrator each described the process used to complete and review the sheets, and both the Staffing Coordinator and Nurse Supervisor stated they were unaware that RNs and LPNs had to be totaled separately.
Surveyors found that the facility did not maintain and post a current daily nurse staffing sheet at the main entrance, as the sheet displayed was several days out of date and did not reflect the current census or staffing. The Scheduler reported preparing and handing off completed staffing sheets to the ADON, who placed them in a staffing binder at the nurse's station with the expectation that nursing staff would update and post them. The DON and Administrator confirmed that the charge nurse was responsible for ensuring the daily nurse staffing sheet was updated and visibly posted for residents and visitors on weekends, but this did not occur on one of the reviewed days.
The facility failed to accurately post daily nurse staffing information when reception staff, using schedules prepared from a master schedule, completed the public staffing report without understanding that some RNs, LPNs, and NAs were splitting shifts or working 12‑hour shifts. Receptionists counted each name on the schedule as a full staff member for the entire shift, did not receive updates on call‑outs or schedule changes, and did not revise the posted report once it was placed in the lobby. The Scheduler did not communicate staffing changes to reception, and the Administrator did not review the report for accuracy, resulting in repeated discrepancies between posted staffing levels and actual scheduled staffing across all three shifts on most days reviewed.
The facility failed to accurately post daily nurse staffing information, with numerous discrepancies between the posted sheets and the internal schedules for RNs, LPNs, MAs, and NAs across multiple shifts. Posted staffing counts often showed higher or lower numbers of staff than were actually scheduled, and in some cases listed staff categories that were not scheduled at all. The staff member responsible for scheduling and postings acknowledged that the postings were not updated when staff called out, did not show, or came in to cover, and leadership confirmed that the postings were expected to match actual staffing but did not.
The facility failed to ensure daily posting of nurse staffing information in a visible area for residents and visitors when the designated Scheduler was not on duty. Surveyors observed that the posted staffing sheet was several days out of date, and interviews revealed that the Scheduler, who did not work weekends, was solely responsible for creating and posting these sheets. The Scheduler acknowledged that no process existed to ensure postings occurred during her absence and that she had not discussed such a process with the Administrator. The Administrator confirmed reliance on the Scheduler and was unaware that staffing information was not being posted when the Scheduler was out of the office.
The facility failed to ensure daily nurse staffing sheets were complete and accurate on numerous days, with required entries for total numbers of RNs, LPNs, NAs, total hours worked for evening and night shifts, and resident census left blank. The Scheduler, who was responsible for completing these sheets, reported that she used the schedule to fill them out but frequently stopped to manage staff call-outs and then forgot to finish the forms, and she was unaware that no blanks were permitted. The DON and Administrator both stated that the Scheduler was responsible for the staffing sheets and acknowledged that the forms were expected to include complete staffing and census information for each shift.
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