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Ohio Department of Health Division of Quality Assurance ...

NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 111111111111111111111111111 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 111111111111111111111111111 Census6 SundayMondayType of SurveyNoDo any residents have fecal impactions?Does the nursing home have residents with any of the following avoidable outcomes: falls, fractures, pressure ulcers, incontinence without toilet plan, restraints, UTI, dehydration, or weight (needs or outcomes) - Please ExplainSaturdayDON - 2nd shiftRN - 2nd ShiftFridayDirect CareTuesdayWednesdayThursday58 Saturday61 YESIf YES in this box, there is a Need to Check the Staffing Schedules6059 Monday625960 Obtain staffing schedul

Ohio Department of Health Home Number Provider Number Division of Quality Assurance Nursing Home Name Minimum Daily Average Staffing Survey Tool 1/28/2002 Nursing Home Capacity Exit Date Are there smells of urine or other unpleasant odors? Are personal care needs of residents, such as assistance with ADLs, being neglected ? 65

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Transcription of Ohio Department of Health Division of Quality Assurance ...

1 NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 111111111111111111111111111 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 111111111111111111111111111 Census6 SundayMondayType of SurveyNoDo any residents have fecal impactions?Does the nursing home have residents with any of the following avoidable outcomes: falls, fractures, pressure ulcers, incontinence without toilet plan, restraints, UTI, dehydration, or weight (needs or outcomes) - Please ExplainSaturdayDON - 2nd shiftRN - 2nd ShiftFridayDirect CareTuesdayWednesdayThursday58 Saturday61 YESIf YES in this box, there is a Need to Check the Staffing Schedules6059 Monday625960 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.

2 Director of Nursing, RN, LPN, Nurse Aide, OT, OT Assistant, PT, PT Assistant, Dietician, Social Worker, and Activities AidesNoSundayTuesdayWednesdayThursdayFri dayWhat day of the week is today?MondayNoAre residents restrained inappropriately?Are medications/treatments administered at the wrong times or missed?Are meals served at inappropriate times?NoYESA nswerIf Yes in this box, there is a Need to Check the Staffing Schedules Answers the following questions related to resident needs:NoNoNoNoNoYesNoRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftDirect CareRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftRN - 1st ShiftTuesdayRN - 1st ShiftRN - 1st ShiftWednesdayThursdayMondayFridaySaturd aySundayRN - 1st ShiftRN - VolunteerAnswers the following questions related to resident outcomes:Are the nursing needs of the residents neglected ?

3 (eg. catheter placement, body alignment, urinary drainage, incontinence, ventilators, oxygen, intravenous fluids, etc.)DON - 1st shiftDoes the Nursing Home have a variance to use LPNs to meet the RN requirement? ohio Department of HealthProvider NumberHome NumberDivision of Quality AssuranceNursing Home NameMinimum Daily Average Staffing Survey Tool1/28/2002 Nursing Home CapacityExit DateAre there smells of urine or other unpleasant odors?Are personal care needs of residents, such as assistance with ADLs, being neglected ? 65 Staffing ProbesAre call lights unanswered?AnswerType of SurveyProvider NumberHome NumberNursing Home NameNursing Home CapacityExit Date651111111111111111111111111111111111 1111111111111111111111111111111111111111 1111111111111111111111111111111111111111 1111111111111111111111111111111111111111 1 11111111111111 11111111111111 11111111111111 1111111111111 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 1111111111111 Nursing NAS

4 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 1111111111111111111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 111111111111111111111111111 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 111111111111111111111111111 SaturdaySundaySaturdaySundaySaturdaySund ayMondayLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftTuesdayWednesdayThursdayFridayFrida yMondayFridayDON - 3rd shiftMondayDirect CareTuesdayTuesdayWednesdayThursdayWedne sdayThursdayLPN - 1st ShiftRN - 3rd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - VolunteerLPN - 1st ShiftRN - 3rd ShiftRN - 3rd ShiftRN - 3rd ShiftRN - 3rd ShiftDirect CareRN - 2nd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - 2nd ShiftRN - 3rd ShiftLPN - 1st ShiftLPN - 1st ShiftLPN - 1st ShiftRN - 3rd ShiftLPN - 1st ShiftRN - 2nd ShiftRN - 2nd ShiftRN - VolunteerRN - 3rd ShiftLPN - 1st ShiftLPN - 1st ShiftRN - 3rd ShiftRN - 3rd ShiftRN - 3rd ShiftRN - 3rd ShiftRN - 3rd ShiftRN

5 - 2nd ShiftLPN - VolunteerLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftDirect CareLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftLPN - 2nd ShiftLPN - VolunteerLPN - 2nd ShiftLPN - 2nd ShiftLPN - 1st ShiftLPN - 1st ShiftLPN - 1st ShiftLPN - 1st ShiftLPN - 1st ShiftRN - 2nd ShiftRN - 3rd ShiftLPN - 1st ShiftRN - 2nd ShiftRN - 3rd ShiftLPN - 1st ShiftType of SurveyProvider NumberHome NumberNursing Home NameNursing Home CapacityExit Date65 Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS1 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 11111111111111 111111111111111111111111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 SundayMondayLPN - 3rd ShiftFridayLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftSaturdayTuesdayWednesdayThursdayNur se Aide 1st ShiftNurse Aide 1st ShiftNurse

6 Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftDirect CareDirect CareNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftLPN - VolunteerLPN - 3rd ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftLPN - 3rd ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftNurse Aide 1st ShiftType of SurveyProvider NumberHome NumberNursing Home NameNursing Home CapacityExit Date651 1111111 1111111 1111111 1111111 111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111

7 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 Nurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 1st ShiftNurse Aide 2nd ShiftNurse Aide VolunteerNurse Aide VolunteerNurse Aide 1st ShiftNurse Aide 2nd ShiftNurse Aide VolunteerNurse Aide VolunteerNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftDirect CareNurse Aide 1st ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 2nd ShiftDirect CareNurse Aide 2nd

8 ShiftNurse Aide 2nd ShiftNurse Aide 3rd ShiftType of SurveyProvider NumberHome NumberNursing Home NameNursing Home CapacityExit Date651 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111111 Nurse Aide 3rd ShiftNurse Aide 3rd ShiftAncillaryOT AssistantantOT AssistantantDieticianNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftAncillaryDieticianOTOTOT AssistantantDieticianDieticianOTOT AssistantantOTOTOTOTOT AssistantantOT AssistantantOTOTOTN urse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide 3rd ShiftNurse Aide VolunteerNurse Aide 3rd ShiftNurse Aide VolunteerDieticianAncillaryOTOTD ieticianDieticianOTOTD ieticianDieticianDieticianNurse Aide 3rd ShiftOT AssistantantOT AssistantantOT AssistantantDieticianDieticianDieticianO TOT AssistantantOT AssistantantOT AssistantantNurse Aide

9 3rd ShiftType of SurveyProvider NumberHome NumberNursing Home NameNursing Home CapacityExit Date651 1111111 1111111 1111111 111111 TuesWedThurFriSatSunMon1 1111111 1111111 1111111 1111111 1111111 1111111 1111111 111

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