Failure to Implement and Monitor RN Coverage and Quality Assurance Processes
Penalty
Summary
The facility failed to implement and maintain appropriate plans of action to address previously identified quality deficiencies, specifically regarding RN coverage. Despite a Plan of Correction (POC) that outlined the use of a pool of RNs from neighboring or sister communities to ensure at least 8 consecutive hours of RN coverage per day, 7 days a week, the facility did not follow through with these arrangements. Record reviews and interviews revealed that there was no RN coverage on multiple dates, particularly during the DON's medical leave and on weekends, as the DON only worked Monday through Friday. The facility also did not utilize telehealth RN services as previously planned, and staff were reportedly not trained or encouraged to use telehealth options. Additionally, the facility failed to conduct weekly reviews of RN coverage in Standard of Care (SOC) meetings as required by their POC, due to the absence of an Administrator and the discontinuation of regular SOC meetings. The facility also did not discuss these quality deficiencies in monthly QAPI meetings for three months, with only one QAPI meeting held during the period in question and no discussion of RN coverage documented. Job postings for RN positions were not provided, and there was no evidence of active recruitment for RNs. These failures resulted in periods without RN oversight, as confirmed by staffing records and interviews with facility staff.