Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours on a specific day, as required by federal regulations. Review of the Nursing Staffing Assignment and Sign-In Sheet for that day showed that no RN Supervisor was present for either the morning or evening shifts. The Director of Staff Development confirmed that the RNs scheduled for those shifts did not report to work—one did not show up and the other called in sick. The Director of Nursing was not scheduled and was also not present, and no replacement RN was arranged for either shift. The facility's own Facility Assessment and staffing plan indicated that an RN Supervisor is needed every day of the week. The RN Supervisor job description outlined responsibilities such as supervising nursing staff, handling personnel issues, reporting to the DON or medical staff, and monitoring incident reports. The absence of an RN on the specified day meant that there was no qualified individual to oversee resident care, supervise staff, or respond to clinical needs as required by the facility's policies and federal regulations.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/03/25, DSD reviewed the rest of the R.N. schedule for June 2025 and found 8 hrs consecutively 7 days a week were covered. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 7/01/25, DSD reviewed the schedule for June 2025, and no other deficient practice was identified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 7/10/25, an RN Supervisor was hired 7:00am-3:30pm Monday through Friday. Starting 6/02/25, DSD and/or DON will utilize Contracted Agency for RN as needed. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance for 3 months.