Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by federal and state regulations. Specifically, there was no RN coverage for two consecutive days, despite a daily census of 101 residents. Review of staffing records confirmed the absence of RN services on these dates, and the facility's policy requires an RN to be present for at least 8 consecutive hours every 24 hours. The Assistant Director of Nursing (ADON) was responsible for the nursing schedule and, upon realizing no regular RN was available for the weekend, attempted to fill the shift with agency staff. When no RN accepted the shift, the ADON filled it with an agency LVN instead, without notifying supervisors until after the fact. Interviews with the ADON, DON, and Administrator revealed that the DON and Administrator were unaware of the lack of RN coverage until after the weekend. The ADON did not escalate the issue prior to the shift, and the change from RN to LVN coverage was only reported to the interdisciplinary team after the weekend had passed. The DON stated that, had she been informed, she could have intervened to provide RN coverage herself. The facility's policy and the statements from leadership confirm that the required RN coverage was not maintained during the identified period.