Failure to Ensure Nurse Coverage on Unit Due to Call-Off and Lack of Relief
Penalty
Summary
The facility failed to ensure that nursing staff followed the established practice of not leaving a unit at the end of a shift without a relief nurse present. On the day in question, a nurse called off for the day shift on the second floor main unit, but the absence was not communicated in a timely manner to the appropriate supervisory staff. As a result, there was no nurse present on the unit for approximately one to two hours, leaving 36 residents without a licensed nurse available. Interviews confirmed that the off-going nurse left before a replacement arrived, and the oncoming nurse was not notified to stay over. The facility's policy requires staff to call off at least four hours before their shift and not to leave without relief, but this protocol was not followed. Review of time cards and controlled substances check forms corroborated that there was no nurse on duty for the affected shift, as no signatures were present for the day shift on the unit. The Director of Nursing was not aware of the call-off until notified by another staff member after the shift had already started. The facility assessment indicated that four nurses were expected to provide direct care on the day shift, but this standard was not met due to the absence and lack of proper handoff. Certified Nursing Assistants (CNAs) were present but are not permitted to pass medications, further impacting care delivery during the period without a nurse.