Failure to Provide Required RN Coverage and Improper DON Role Assignment
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present to provide services for 8 consecutive hours each day, 7 days a week, as required. Review of RN staffing timesheets from October 2024 through April 2025 revealed multiple dates where the RN did not work the required 8 consecutive hours, with some days showing less than 8 hours worked and one day with no RN hours worked at all. Interviews with the Director of Nursing (DON), the RN, and the accounting staff confirmed these discrepancies and verified that the facility census was consistently above 60 residents during this period. Additionally, the facility did not comply with the regulation that prohibits the DON from serving as a charge nurse when the census exceeds 60 residents. On days when the scheduled RN was absent or worked less than 8 hours, the DON assumed RN duties, but was classified as working under the DON role and did not use the electronic clock in/out system. Both the DON and the Administrator acknowledged they were unaware that the DON could not serve dually as the RN and DON when the census was above 60, and confirmed that the census had not dropped below this threshold for several months.