Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Payroll Based Journal (PBJ) staffing data and schedule reviews revealed that on several dates, the facility did not meet the required RN coverage. Specifically, there were multiple days during the third and fourth quarters of the fiscal year 2024 when RN hours were insufficient. On some of these dates, the Director of Nursing (DON), who is an RN, was present, but the facility census was below 60 residents, which is relevant to the regulatory requirement. Interviews with the Administrator and review of staffing records confirmed ongoing challenges in hiring and retaining RNs during the period in question. The Administrator, who started in June 2024, acknowledged difficulties in recruiting RNs, which contributed to the lapses in required RN coverage. The deficiency had the potential to affect all 54 residents residing in the facility at the time.