Failure to Provide 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide 24-hour licensed nursing staff coverage in the skilled nursing unit, resulting in a five-hour period without a licensed nurse present for a census of 73 residents. According to the facility's own policy, licensed nurses and certified nursing assistants are required to be available at all times to ensure resident safety and to provide necessary care. On the night in question, two licensed nurses scheduled for the overnight shift called in and did not report to work. The two nurses from the previous shift extended their hours but left at 2:00 a.m., leaving the unit without licensed nurse coverage from 2:00 a.m. to 7:00 a.m. Interviews with staff confirmed that attempts were made to contact the DON, Director of Staff Development, and the Administrator to find replacements, but no licensed nurse arrived to cover the shift. The staffing scheduler acknowledged that a third name was incorrectly added to the staffing sheet without verification or an employee signature, confirming that this individual did not work the shift. As a result, the skilled nursing unit was left without the required licensed nurse coverage for five hours.