Failure to Post Nurse Staffing Information on East Wing
Summary
The facility failed to ensure that nurse staffing information was posted in a manner that was beneficial to residents and the public on the East Wing of the facility. According to the facility's policy, staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census, should be posted daily at the beginning of each shift in a clear and readable format. This information should be placed in a prominent location that is readily accessible to residents and visitors. However, during observations at 10:12 AM and 5:45 PM, the staffing board on the East Wing was found to be unchanged, displaying only two nursing staff names and three Certified Nursing Assistant staff names for the 7 AM to 3 PM shift, with no room numbers or shift data posted. The facility's policy also requires that the posted nurse staffing data be maintained for a minimum of 18 months or as required by state law, whichever is greater. Additionally, the facility must make nurse staffing data available to the public upon request. The failure to update the staffing board as required by the facility's policy and state regulations indicates non-compliance with the staffing standards, which are intended to ensure transparency and accessibility of staffing information for the benefit of residents and the public.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. Re-education provided to East wing nurse from 7am-3pm and East wing nurse from 3pm-11pm by NHA on the requirement to post nurse staffing information in a way to benefit the residents and public. 2. No other areas or residents were affected by deficient practice. 3. Reeducation was provided to nursing staff by DON or designee on requirement for posting up-to-date staffing information daily. 4. The Director of Nursing or designee will complete quality assurance check weekly 5X a week for 6 weeks then 3X a week for an additional 6 weeks to ensure up-to-date staffing information is posted daily. 5. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Penalty
Surveyors found that the facility did not post the current date on Nurse Staffing Information forms in two observed areas, as required. Staff explained that the process relied on the night nurse to update postings at midnight, but the previous day's forms remained displayed. The Administrator and DON confirmed the requirement for daily, current postings.
The facility did not properly post daily nursing staff information, as required, by listing only names without titles or unit assignments. This made it unclear which nurses or CNAs were responsible for specific residents, and both surveyors and residents could not determine staff assignments from the posted information. The ADON acknowledged these deficiencies.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily Nurse Staffing Information was posted with the current date in two of five observed posting areas. During an entrance tour, surveyors observed that the 'Nursing Staff Posting Form' at both the front desk and the main hallway bulletin board displayed outdated dates, despite the form itself indicating it should be updated daily. Photographic evidence was obtained to document these findings. Interviews with staff revealed that the Staffing Coordinator prepared the next day's staffing form in advance and placed it behind the current day's form, with the expectation that the night nurse would update the posting at midnight. However, on the day of the survey, the previous day's forms remained posted in both observed areas. Both the Administrator and the DON acknowledged that the Nurse Staffing Information Form is required to be posted daily with the current date.
Plan Of Correction
1.) Staff posting was completed by the Staffing Coordinator, the Resident Council President was notified, and no additional recommendations were provided on behalf of the resident council committee. 2.) A full house audit of staff posting areas was completed by the Nursing Home Administrator, and staff posting was updated. A resident council meeting was held; no residents were affected by this. 3.) Staffing coordinator educated by the Nursing Home Administrator/Designee on updating the staff posting throughout the facility each day, and the components of regulation F732/N066. 4.) Nursing Home Administrator/Designee will conduct random audits to ensure staff posting is current, accurate, and visible to the residents twice weekly for four weeks, then weekly for four weeks then monthly for three months to ensure compliance. Findings of audits to be reported through the monthly Quality Assessment, Assurance and Compliance Committee meeting for three months for comments and recommendations.
Failure to Properly Post Nursing Staff Information
Penalty
Summary
The facility failed to comply with statutory requirements for daily posting of nursing staff information. During observations, the posted staff list across from the nursing station included only names, without specifying titles such as licensed nurses or certified nursing assistants (CNAs). Additionally, the posting did not indicate room assignments for the four units, making it unclear which staff members were responsible for specific residents. Surveyors had to ask staff to determine which personnel were assigned to particular residents, and random residents questioned were unable to identify their assigned nurse by looking at the posted information. The Assistant Director of Nursing confirmed these findings during an interview.
Plan Of Correction
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator during staffing meetings will continue to ensure compliance with the requirement. On weekends, the Director of Nursing will verify with the Supervisor and monitor callouts for replacements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The missing staffing information such as titles and room assignments for the Certified Nursing Assistants and Licensed Nurses identified were corrected. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Meeting scheduled with the resident council on to review the posted assignments to ensure understanding. Random residents will be questioned on who their assigned nurses and the Certified Nursing Assistants are to ensure understanding. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nurse Managers and Licensed Nurses have been re-educated regarding posting nurse staffing information to include titles and room assignments. Weekly audits will be completed to ensure compliance times four weeks. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met.
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