Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was onsite for at least 8 consecutive hours per day, 7 days a week, as required. Review of the payroll based journal (PBJ) staffing report for the first quarter of 2025 revealed multiple days with either no RN hours reported or insufficient RN coverage. Specifically, there were several dates with no RN coverage at all, and at least one date with only 4 hours of RN coverage. Facility payroll and staffing schedules confirmed these gaps in RN coverage. Interviews with facility staff, including the regional nurse consultant, assistant director of nursing (ADON), and staffing coordinator, confirmed the lack of RN coverage on the identified dates. The staffing coordinator acknowledged ongoing difficulties in maintaining RN coverage, particularly on weekends, and stated that only two RNs were employed at the facility, with one working full time overnight and the other recently starting on evenings. The facility's own policy requires an RN to provide services for at least 8 consecutive hours every 24 hours, 7 days a week.