Failure to Provide Required RN Coverage and Accurate PBJ Reporting
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, as required. Review of Payroll Based Journal (PBJ) data and daily timecard reports for multiple dates in October, November, and December 2024 revealed that there were no RN hours recorded on several days. Interviews with the staffing coordinator and human resources staff confirmed that there were ongoing challenges with RN staffing, including difficulties retaining nurses, reliance on agency nurses, and scheduling issues such as a nurse not working on Saturdays for religious reasons and another only working weekdays. Additionally, the facility experienced disruptions during hurricanes, with staff working in different buildings and possible power outages affecting the time clock system, which may have contributed to incomplete or missing RN hour records. The nursing home administrator, who started after the period in question, acknowledged that agency nursing hours had not been submitted to the payroll company, resulting in inaccurate PBJ data. The facility's staffing policy requires sufficient licensed nurses and certified nursing assistants to provide care 24 hours a day and mandates that all direct care staffing information, including agency and contract staff, be submitted to the CMS PBJ system. However, the failure to record and report RN hours on the specified dates led to noncompliance with federal staffing requirements.