Failure to Ensure Adequate RN Coverage and Accurate Staffing Documentation
Penalty
Summary
The facility failed to implement and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of staffing documentation for a specific date revealed discrepancies between the assignment sheet, PBJ data, and timesheet punches, with only one RN verifiably working and no way to confirm the presence of an LPN as documented. Additionally, contract staff timesheets were requested but not provided, further limiting verification of staffing levels. A review of facility schedules and timesheets over a three-month period identified multiple days with no RN coverage. Specifically, there were two days in January, three days in February, and one day in March without RN coverage. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility had implemented tracking of RN coverage and staff shortages. However, the facility assessment staffing plan only required one RN or LPN per shift, and there were documented gaps in RN coverage that were not addressed or verified through available records.