Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day on five specific dates within the reviewed period. Review of daily nurse staffing sheets and time clock reports revealed that on these dates, there was no documentation of an RN being present for the required duration. Staff interviews confirmed that there were times when no RN was scheduled for the full 8 to 12 hours, and the Central Supply Manager, who was responsible for scheduling, would notify the Former Administrator when this occurred. The Former Administrator acknowledged awareness of the issue, particularly on weekends, and described attempts to address it by alternating the MDS Nurse and Treatment Nurse, both RNs, on weekends, but could not recall when this system was implemented. The Regional Director of Clinical Operations also confirmed the lack of documentation for RN coverage on the identified dates and noted that there may have been instances of call-outs or staff working at a sister facility, which contributed to the deficiency. The report does not mention any specific residents affected or provide details about their medical conditions at the time of the deficiency. The deficiency was identified through record review and staff interviews, which consistently indicated that the facility did not meet the regulatory requirement for RN coverage on the specified dates.