Other·November 23, 2022

§483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/11/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors on 10/14/2022. During an observation and interview on 10/14/2022, at 8:22 a.m., with the Director of Nursing (DON), observed nurse staffing not posted in Nursing Station 1. The DON stated that the staffing should be posted on the nurses' station on a conspicuous place where everybody can see them. She will follow up with Director of Staff Development (DSD) to have the staffing posted. The DON was informed that yesterday the staffing was also not posted. During an observation and interview on 10/14/2022, at 8:26 a.m., with the DSD, observed nursing staffing not posted in Nursing Station 2. The DSD stated that she, together with the Human Resources (HR) were responsible for posting the staffing. The DSD was made aware also that yesterday the staffing information was not present on the nursing stations. The DSD stated that it should have been posted in the nursing stations where everybody can see to assure families and residents that they have enough staffing to provide safe care. The DSD stated that she forgot to post them. A review of the facility's recent policy and procedure titled "Posting Direct Care Daily Staffing Numbers," dated 10/13/2021, indicated that within two (2) hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses [RNs], Licensed Practical Nurses [LPNs], and Licensed Vocational Nurses [LVNs]) and the number of unlicensed nursing personnel (Certified Nursing Assistants [CNAs]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors on 10/14/2022. The above violation had direct or immediate relationship to the health, safety, or security of all residents.