Failure to Provide Required RN Coverage and Resident Assessment
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, as required. Specifically, for four out of nine weekends reviewed, there was no RN present in the building for periods ranging from 36 to 48 hours. During these times, the facility relied on Licensed Practical Nurses (LPNs) who would contact the Director of Nursing (DON) by phone for guidance, but there was no documentation that the DON or any other RN was physically present or had assessed residents during these periods. The facility's staffing policy and assessment indicated the expectation of having sufficient RN coverage, including the DON as a full-time RN and additional RN managers and supervisors, but these staffing goals were not met. During the periods when no RN was present, several incidents occurred involving residents. Two residents fell out of bed, with one sustaining a bloody nose and another complaining of hip pain, but neither was assessed by an RN. Another resident sustained a burn on the thigh and was not assessed by qualified staff until two days later by a wound care physician. Interviews with the staffing coordinator and DON confirmed that there were times when no RN was scheduled, and the DON would only provide guidance remotely without documentation of being on duty or assessing residents in person. The administrator acknowledged awareness of the RN staffing gaps, particularly on weekends and night shifts.