Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least 8 consecutive hours per day, 7 days a week, as required by federal regulations. Record review of staffing forms and RN time sheets revealed that on two separate days, the number of RN hours worked fell below the required 8 consecutive hours. Specifically, on one day, only 7.87 hours were worked, and on another, only 5.42 hours were worked. Further examination of RN time sheets confirmed that on these days, the RN clocked in and out in a manner that resulted in less than the required consecutive hours of coverage. Interviews with the Labor Coordinator and the Nursing Home Administrator confirmed that no other RN worked on those days to supplement the hours, and there were no call-offs reported. The Labor Coordinator acknowledged the discrepancy as a mistake, and the Administrator verified the shortfall in RN coverage. The deficiency was identified through review of facility records and staff interviews, with no mention of resident-specific incidents or medical histories related to the deficiency.
Plan Of Correction
F727-RN 8 Hrs/7 days/wk What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Administrator completed a comprehensive review of RN hours for the previous 2 weeks and found that there were 8 consecutive hours of RN coverage. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , Audit was completed by Administrator/designee of Staffing hours for past 2 weeks to ensure that Staffing requirements are met, Including 8 consecutive RN hours every day of the week day. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By /205, the Staffing coordinator, Administrator and Human Resources and Director of Nursing will be educated on the components of F727 with an emphasis on 8 consecutive hours seven days a week of RN hours per day and schedule requirements by the Regional Vice President of Operations/Designee. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/Designee to conduct audits of staffing report 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that Staffing requirements are met and that there are 8 consecutive RN hours every day of the week. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.