Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, over a three-month period from October 1 to December 31, 2024. Review of the facility's payroll-based journal (PBJ) Staffing Data Report and Direct Care Service Hours Per Patient Day (DHPPD) reports confirmed that there were multiple days with no RN hours recorded, and interviews with facility staff, including the Facility Assistant (FA), a licensed nurse, and the Director of Nursing (DON), revealed that the DON was the only RN associated with the facility. The DON was not scheduled regularly and only came in on an as-needed basis, such as to cover call-offs or last-minute absences, and was not present for eight consecutive hours each day. Further review of facility policy indicated that an RN should provide services for at least eight consecutive hours every 24 hours, seven days a week. However, both staffing records and staff interviews confirmed that this requirement was not met, as there was no consistent RN coverage during the period in question. The DON acknowledged the lack of compliance with the RN coverage requirement, and the FA confirmed that from January 2025 onward, there continued to be no RN scheduled to work at the facility.