Ohio Department of Health Division of Quality Assurance ...

Nursing Home Name Nursing Home Capacity

Ohio Department of Health

Division of Quality Assurance Minimum Daily Average Staffing Survey Tool

1/28/2002

Home Number

Provider Number

65

Exit Date

Type of Survey

Staffing Probes

1 Answers the following questions related to resident needs:

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 ? D. Are the nursing needs of the residents neglected ? (eg. catheter placement, body alignment, urinary drainage, incontinence,

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

2 Answers the following questions related to resident outcomes:

A. Do any residents have fecal impactions? B. 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 loss. C. Other (needs or outcomes) - Please Explain

If YES in this box, there is a Need to Check the Staffing Schedules

Answer

No No No

Yes No No No YES Answer

No

No No YES

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 3 YES including: Director of Nursing, RN, LPN, Nurse Aide, OT, OT Assistant, PT, PT Assistant, Dietician, Social Worker, and

Activities Aides

4 Does the Nursing Home have a variance to use LPNs to meet the RN requirement?

No

5 What day of the week is today?

Monday

6

Census

Tuesday

58

Wednesday

62

Thursday

59

Friday

60

Saturday

61

Sunday

60

Monday

59

Direct Care

DON - 1st shift

RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - 1st Shift RN - Volunteer

Direct Care

DON - 2nd shift RN - 2nd Shift

Tuesday Wednesday Thursday

Friday

Saturday

Sunday

Monday

Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tuesday

Nursing NAS

1

1

1

1

Wednesday

Nursing NAS

1

1

1

1

Thursday

Nursing NAS

1

1

1

1

Friday

Nursing NAS

1

1

1

1

Saturday

Nursing NAS

1

1

1

1

Sunday

Nursing NAS

1

1

1

1

Monday

Nursing NAS

1

1

1

1

Nursing Home Name

Home Number

Provider Number

Nursing Home Capacity

65

Exit Date

Type of Survey

RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - 2nd Shift RN - Volunteer

Direct Care

DON - 3rd shift

RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - 3rd Shift RN - Volunteer

Direct Care

LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - 1st Shift LPN - Volunteer

Direct Care

LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - 2nd Shift LPN - Volunteer

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tuesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tuesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tuesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Wednesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Wednesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Wednesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Thursday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Thursday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Thursday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Friday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Friday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Friday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Saturday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Saturday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Saturday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Sunday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Sunday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Sunday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Monday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Monday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Monday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Nursing Home Name

Home Number

Provider Number

Nursing Home Capacity

65

Exit Date

Type of Survey

Direct Care

LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - 3rd Shift LPN - Volunteer

Tuesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Wednesday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Thursday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Friday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Saturday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Sunday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Monday

Nursing NAS

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Direct Care

Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift

Tues Wed Thur Fri

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Sat Sun Mon

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Nursing Home Name

Home Number

Nursing Home Capacity

65

Exit Date

Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide 1st Shift Nurse Aide Volunteer Nurse Aide Volunteer

Direct Care

Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide 2nd Shift Nurse Aide Volunteer Nurse Aide Volunteer

Direct Care

Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift Nurse Aide 3rd Shift

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tues Wed Thur Fri

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Tues Wed Thur Fri

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

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1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

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Provider Number Type of Survey

Nursing Home Name

Nursing Home Capacity

Nurse Aide 3rd Shift

1

Nurse Aide 3rd Shift

1

Nurse Aide 3rd Shift

1

Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

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Nurse Aide 3rd Shift

1

Nurse Aide 3rd Shift

1

Nurse Aide 3rd Shift

1

Nurse Aide Volunteer

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Nurse Aide Volunteer

1

65

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Home Number

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Ancillary

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician

Dietician Dietician

Ancillary

OT OT OT OT OT OT OT OT OT OT OT OT OT OT OT

Ancillary

OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant OT Assistantant

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Provider Number Type of Survey

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