Ohio Department of Health Division of Quality Assurance Minimum Daily Average Staffing Survey Tool 1/28/2002
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1 Ohio Department of Health Division of Quality Assurance Minimum Daily Average Staffing Survey Tool 1/28/ Answers the following questions related to resident needs: D. Are the nursing needs of the residents neglected? ventilators, oxygen, intravenous fluids, etc.) E. Are residents restrained inappropriately? F. Are medications/treatments administered at the wrong times or missed? G. Are meals served at inappropriate times? If Yes in this box, there is a Need to Check the Staffing Schedules Staffing Probes A. Are call lights unanswered? B. Are there smells of urine or other unpleasant odors? C. Are personal care needs of residents, such as assistance with ADLs, being neglected? (eg. catheter placement, body alignment, urinary drainage, incontinence, 2 Answers the following questions related to resident outcomes: A. Do any residents have fecal impactions? Does the nursing home have residents with any of the following avoidable outcomes: falls, fractures, pressure ulcers, B. incontinence without toilet plan, restraints, UTI, dehydration, or weight loss. C. Other (needs or outcomes) - Please Explain If YES in this box, there is a Need to Check the Staffing Schedules Answer Yes YES Answer YES 3 Obtain staffing schedules for today and the previous 6 days for all direct care staff if the answers to ANY of the above questions are YES including: Director of Nursing, RN, LPN, Nurse Aide,, Assistant,, Assistant,, Social Worker, and 4 Does the Nursing Home have a variance to use LPNs to meet the RN requirement? 5 What day of the week is today? Monday 6 Census Tuesday Wednesday Thursday Friday Saturday 61 Sunday Monday DON - 1st shift RN - Volunteer DON - 2nd shift
2 RN - Volunteer DON - 3rd shift RN - Volunteer LPN - Volunteer LPN - Volunteer
3 LPN - Volunteer
4
5 Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant Assistantant
6 Assistantant Assistantant Assistantant Volunteer Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Volunteer Activities Director Activities Volunteer Activities Volunteer
7 Social Volunteer Social Volunteer Initial here when you have entered all the hours aa Staffing Requirement Category 1st shift 1 to 15 requirement NAS* 2nd shift 1 to 15 requirement NAS* 3rd shift 1 to 15 requirement NAS* YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES If there are two instances of non-compliance in any one category (eg, RN requirement, 1 to 15 requirement) or three instances of noncompliance from any category, then cite for not meeting minimum staffing requirement. NA requirement 2.00 RN requirement.20 Direct care requirement.55 *NAS = Nurse Aide Services Surveyor Name Date If the home meets the staffing minimums and resident needs are not met, then paragraph (F) may be cited if there is at least one care violation also cited tes:
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