Failure to Maintain RN Coverage and Active DON License
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 out of 54 days reviewed. This was identified through a review of facility policy, employee time sheets, and interviews. The facility's staffing policy requires sufficient numbers of staff with the necessary skills and competency to provide care and services for all residents. However, time sheet reviews revealed multiple dates where no RN was present for the required 8-hour period, and the facility was unable to provide additional documentation for those dates when requested. During interviews, the DON acknowledged that there should be an RN on duty daily and confirmed that her own time was sometimes manually entered when she covered RN shifts, but also noted she was off during one of the weeks in question. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a current and active nursing license during the review period. A check of the State of Tennessee Department of Health Division of Health Licensure website showed the DON's license had lapsed, and the DON confirmed in an interview that her license had expired and was later renewed. These findings indicate lapses in both staffing and licensure compliance as required by facility policy and state regulations.