Incomplete Daily Staffing Posting: The facility failed to ensure the daily staffing posting included all required information. The posting showed the date and the total number of licensed staff with their designation, but it did not include the facility name, a clearly identified census, or the total actual hours worked by licensed staff. The senior manager of scheduling operations, RN-A, the DON, and the administrator gave differing accounts of who was responsible for updating weekend changes and acknowledged uncertainty about the exact posting requirements.
Daily staffing postings on all three units showed staff names and disciplines, but the hours scheduled and current census were not visible. The DON confirmed the census was not included, and the administrator verified that the hours on the back of the posting reflected the prior day's schedule because the new posting had been placed on top of it.
Surveyors found that required daily nurse staffing information was not posted anywhere in the building, including the administrator’s office door, primary areas, hallways, or entrance. The administrator acknowledged responsibility for posting the information and admitted it was not printed or posted. Facility policy required that nurse staffing information be posted daily, seven days a week, in a readable format and be readily available to residents and visitors, but this was not done, potentially affecting all 33 residents and visitors seeking this information.
The facility posted inaccurate nurse staffing information by listing an RN for a day shift when, in fact, an LPN worked that shift. The DON discovered the error after verifying the nurse's license, resulting in a staff posting that did not reflect the actual personnel on duty. This inaccuracy had the potential to affect all residents in the facility.
The facility did not consistently post up-to-date nurse staffing information as required, with outdated postings and incorrect resident census numbers observed. The DON and scheduler confirmed that postings were often prepared in advance and not always updated to reflect current census or staffing changes, leading to inaccurate information being displayed.
The facility did not ensure that posted nurse staffing information accurately reflected the actual number of CNAs and total hours worked, as required by policy. The posted schedule was not updated to account for staff call-outs or last-minute changes, resulting in discrepancies between posted and actual staffing data. This issue was confirmed by both the DON and the staffing coordinator.
The facility did not accurately post the actual hours worked by RNs, LPNs, and CNAs on the daily nurse staffing form, instead only listing the number of staff and total hours per role. The DON confirmed that actual hours worked were only available in staff schedules at nursing stations, not in the required public posting, affecting all residents and visitors seeking this information.
Required nurse staffing information was not updated daily and did not include the facility name, as observed in the main lobby. Staff interviews revealed uncertainty about who was responsible for updating the posting during the staffing coordinator's absence, and it was confirmed that the omission of the facility name had persisted for several months.
The facility did not include the daily resident census on the nurse staffing posting, despite displaying other required staffing information. The census was omitted on nearly all reviewed days, and staff confirmed they were not trained or instructed to include it. The census was only recorded in a non-public area, making it inaccessible to residents and visitors.
The facility did not consistently include all required information on daily nurse staffing postings, with missing elements such as facility name, date, census, and staff details on multiple occasions. This was confirmed by administrative staff, and no policy for staff posting was available when requested.
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