Failure to Ensure Required RN Coverage Due to Lapsed Waiver and Scheduling Issues
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours each day, as required, for multiple days across two fiscal quarters. Payroll Based Journal (PBJ) reports, nurse schedules, and staff timecards revealed that there was no RN coverage for eight consecutive hours on ten days in quarter four of fiscal year 2024 and seven days in quarter one of fiscal year 2025. The Director of Nursing (DON) initially believed the facility had an RN staffing waiver in place, but review of the waiver application showed that the waiver had expired and was not reapproved by the required date. The facility attempted to reapply for the waiver, but the state health department instructed them to wait until after the next recertification survey. During this period, there were documented days with no RN scheduled for the required hours. Interviews with the DON and the administrator revealed a lack of awareness regarding the expiration of the RN waiver and the ongoing requirement for RN coverage. The administrator was responsible for submitting the waiver renewal but was unaware of the renewal deadline, only realizing the lapse months later. The DON confirmed that there were days without the required RN coverage and also stated that the facility did not have a staffing policy in place. No information about specific residents or their conditions was provided in the report.