Missing Local Health Officer Contact Information at Nursing Stations
Summary
The facility failed to ensure that the name, address, and telephone number of local health officers were available in all four nursing stations, as required. During observations and interviews, staff members at Nursing Stations 1, 2, 3, and 4, including a registered nurse, the infection prevention nurse, and the assistant director of nursing, were unable to locate this information at their respective stations. The director of nursing confirmed that this contact information was not present in any of the nursing stations, which is necessary for staff to easily access local health officer contact details for guidance.
Plan Of Correction
C1285 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, the Administrator Assistant posted updated information for the current Local Health Officers at all four nursing stations. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - On 9/24/25, the Administrator Assistant verified that all four nursing stations had the current Local Health Officers information posted. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25 and 10/10/25, the Administrator Assistant conducted an in-service training to educate staff on the location and accessibility of the Local Health Officers' information. - Starting 10/14/25, the Administrator Assistant will monitor the posting of the Local Health Officers' information at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Penalty
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