Failure to Provide Required RN Coverage and Accurate Staffing Documentation
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours each day, seven days a week, for seventeen out of ninety-one days during the third quarter of Fiscal Year 2025. Payroll Based Journal (PBJ) data review revealed that on multiple specific dates, there were no RN hours reported. Interviews with the staffing coordinator and the Director of Nursing (DON) confirmed that on these dates, no RNs were available to fill the required shifts, and the facility did not utilize temporary or contracted staff to cover these absences. The staffing coordinator described the process for attempting to fill RN shifts, which included contacting current staff, then the Assistant Director of Nursing (ADON), and finally the DON, but acknowledged that on the identified dates, no RNs were available to provide coverage. Further review indicated that the facility's reporting to the PBJ system was miscoded due to errors by a contracted human resources department, resulting in the absence of documented RN hours for the periods in question. The DON and the Nursing Home Administrator (NHA) stated that the facility generally maintains a minimum of two LPNs and RNs on staff at all times, but due to the miscoding and lack of supporting data, they were unable to demonstrate compliance with the requirement for RN coverage. Facility policies and job descriptions reviewed confirmed the responsibility to ensure adequate RN staffing and accurate reporting, but these were not met during the identified period.