Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that for a period of 21 days, from December 7, 2024, to December 27, 2024, the facility did not have an RN on duty for the required hours. Specific shifts on multiple days were noted where no RN hours were worked, despite the requirement for 8 hours of RN coverage per shift. The deficiency was confirmed during an interview with the Nursing Home administrator on January 2, 2025, who acknowledged the absence of an RN for the required shifts on the specified dates. This lack of RN coverage is a violation of the federal regulation §483.35(b) and the state codes 28 Pa. Code 201.18(e)(1) and 28 Pa. Code 211.12(c), which mandate adequate nursing services and management in long-term care facilities.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure the facility provides the services of a Registered Nurse (RN) for 8 consecutive hour nursing shifts daily. The scheduler or designee will review projected staffing levels via the daily log to ensure that any foreseeable issues with regard to adequate RN coverage is met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. 1 Full Time day shift Registered Nurse, 1 Full Time night shift Registered Nurse and Director Of Nursing began in General Orientation 1/16/25. Scheduler and nursing supervisors have been educated on required RN/DON staffing requirements. Results of audits will be reviewed at Quality Assurance committee 2/28/25 Date of compliance.