Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours each day, 7 days a week, as required. Policy review indicated the facility was to provide sufficient qualified nursing staff at all times, including a minimum of .55 hours of licensed nursing staff per resident day. However, review of working schedules, calculated time reports, and employee timesheets revealed that there was no RN coverage on 37 specific days between January and June 2025. These absences were confirmed for multiple weekends, with both the RN and the Director of Nursing (DON) not present or working on those days. Interviews with the DON and the Administrator confirmed the lack of RN coverage on weekends, and it was stated that in the absence of an RN, the charge nurse would contact the DON or another RN, or rely on an RN from a sister facility in emergencies. The facility had applied for a waiver for this requirement, but it had not been granted at the time of the survey. The census during this period was 35 residents.