Failure to Maintain 24-Hour Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide licensed nursing coverage for 24 hours a day as required, based on review of payroll and other verifiable data for one quarter. On a specific day, documentation showed that only one registered nurse was verifiably present for the shift, while the presence of a contract LPN could not be confirmed through timesheet punches or other auditable records. The assignment sheet and PBJ data indicated that both an RN and an LPN were scheduled and reported as working, but only the RN's hours could be substantiated. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility aimed to overstaff to meet resident needs. However, the facility was unable to provide contract staff timesheets to verify the LPN's presence for the shift in question. The facility's staffing plan required at least one RN or LPN per shift, but the lack of verifiable documentation for the LPN resulted in a failure to demonstrate compliance with 24-hour licensed nursing coverage, potentially affecting all 39 residents.