Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) as the Director of Nursing (DON) on a full-time basis from November 11, 2024, to December 7, 2024. An interview with the Nursing Home Administrator (NHA) on December 9, 2024, revealed that Employee 1, who was serving as the Interim Director of Nursing, did not work at least 35 hours a week in this role. Instead, she was required to cover as the RN on the nursing care units. A review of the interim DON's timecard for the specified weeks showed that Employee 1 only worked two days as the interim DON and was utilized as the RN on the nursing care units on multiple dates. The NHA confirmed these findings during a meeting on December 9, 2024, acknowledging that the facility did not have a designated RN serving as the DON on a full-time basis, as required by PA Code: 211.12(b)(c) Nursing services.
Plan Of Correction
1. 1st Shift RN Supervisor was sitting in as Interim Director of Nursing prior to Full-time Director of Nursing being hired. When no RN supervisor was available to work 1st shift, the Interim Director of Nursing was pulled to be RN Supervisor. 2. A full-time Director of Nursing was hired and had an official start date of 12/16/2024. 3. Administrator will ensure to monitor weekly that the Director of Nursing completes at least 35 hours a week of Director of Nursing duties.