Failure to Appoint RN as Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required by federal regulations. Instead, the DON position was filled by an LPN, and there was a period when the facility had no DON at all. This was confirmed through interviews with the Assistant Nursing Home Administrator and the Assistant Director of Nursing, both of whom stated that after the previous DON, who was an RN, resigned, there was a gap before the LPN was hired as DON. During this time, the ADON, also an LPN, was the only nursing leadership present. The surveyor reviewed multiple complaint investigations and the facility's grievance log during the period when the LPN was serving as DON. Several complaint investigations resulted in citations related to pharmacy services, food procurement, catheter care, bedhold, notice of transfer, Ombudsman notification, CPR, intravenous fluids, medication errors, and quality assurance activities. The grievance log showed a notable number of grievances filed during the months when the LPN was acting as DON, indicating ongoing concerns during this period.