The facility failed to ensure daily nurse staffing postings were accurate and complete. Surveyors observed multiple posted staffing sheets that did not include total hours worked and, at one point, did not list the facility name. Review of additional dates showed the same omission of total hours worked. An administrative nurse reported that a night-shift nurse completed and posted the next day’s staffing sheet and indicated that a column labeled "actual hours" was intended to represent total hours worked, despite the facility’s written policy requiring clear computation and recording of staffing levels and census information on the Daily Nurse Staffing form.
Surveyors found that daily nurse staffing information was not consistently posted or retained as required. Over an 18‑month review period, multiple days of staffing records were missing, and the sheet displayed during observation was not for the current date. Staff interviews showed that an administrative staff member was responsible for weekday postings and record retention, while charge nurses were expected to post and update prefilled sheets on weekends. A changeover in the personnel responsible for maintaining these records contributed to the inability to locate all required historical staffing sheets, despite a written policy requiring timely posting and 18‑month retention of nurse and CNA staffing data.
The facility did not ensure that daily nurse staffing sheets accurately reflected actual hours worked by RNs, LPNs, and CNAs. On the day reviewed, the posted staffing form, observed twice near the nurse’s station with a census of 40 residents, lacked actual hours worked per shift for licensed and unlicensed staff providing resident care. An LN and administrative nurses reported that nurses did not update the posted sheet when staff were late or absent and that the business office added actual hours at the end of the week, contrary to facility policy requiring real-time updates after each shift.
The facility did not follow its policy requiring daily posting of nurse staffing information for each shift. Surveyors observed that three houses lacked accurate or current staffing sheets, with the last posted date more than a month old, despite an active resident census. An administrative staff member confirmed that staffing sheets were expected to be completed and posted daily for all licensed and unlicensed staff directly responsible for resident care.
The facility failed to follow its policy for posting daily nurse staffing information by not including the actual hours worked by nursing staff on the publicly posted staffing sheets. On multiple observed occasions and in prior records, the sheets lacked required details about actual time worked for each category and type of nursing staff, despite the facility’s policy specifying that this information, along with census and staffing categories, must be recorded and posted. Administrative staff and a CMA responsible for staffing confirmed that the posted sheets did not contain the actual hours worked.
The facility did not consistently post daily nurse staffing sheets with the actual hours worked by licensed and unlicensed staff, as required. On several observed days, the posted sheets lacked this information, and administrative staff confirmed that actual hours were omitted if they matched scheduled hours, contrary to facility policy.
The facility did not accurately post daily nurse staffing information, failing to update postings to reflect actual hours worked by RNs, LPNs, and CNAs, as well as changes due to call-ins, meal breaks, or coverage adjustments. Administrative staff confirmed a lack of awareness and action regarding these required updates.
The facility did not maintain or retain daily posted nurse staffing data for the required period, as confirmed by record review and staff interviews. The DON was identified as ultimately responsible for ensuring compliance with the facility's policy, which mandates that nurse staffing information be readily available and kept for at least 18 months.
The facility did not post required daily nurse staffing information for several days, as confirmed by administrative staff and direct observation. The missing postings included details such as the facility name, date, census, and actual hours worked by RNs, LPNs/LVNs, and CNAs, in violation of facility policy.
The facility did not accurately post daily nurse staffing information as required, as the actual hours worked by nursing staff were not completed on the daily staffing sheets for 35 residents. This was confirmed by an administrative nurse and was not in accordance with the facility's policy mandating the posting of shift data and total hours worked.
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