Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide a licensed nurse on the premises on a 24-hour basis, specifically during the overnight shift from 11/11/25 to 11/12/25, when the only scheduled LPN left the facility. Review of staffing records and timecards confirmed that the LPN clocked out at 1:15 AM, leaving the facility without a licensed nurse on site for several hours while 37 residents were present. Staff interviews revealed that the LPN had a pattern of leaving the building or being unaccounted for during overnight shifts, often leaving his phone at the nurses' station and instructing CNAs to call him if needed, though he was sometimes unreachable. On the night in question, the LPN left the facility to get gas and was subsequently detained by law enforcement after a traffic stop. CNAs reported being unaware that the LPN had left the premises and were unable to locate him when needed for resident care, including when a resident developed a fever. The DON was notified by staff and law enforcement after the LPN was taken into custody, and EMS was dispatched to the facility to provide medical coverage until the DON arrived. Staff interviews indicated that concerns about the LPN's absences had been previously reported to the DON, but there was no documentation of disciplinary action or ongoing concerns in the staff records. Facility policy and the facility assessment both required a licensed nurse to be present 24 hours a day to provide direct resident care. Despite this, the LPN was the only nurse scheduled for the overnight shift and left the premises, resulting in a period where no licensed nurse was available to meet residents' needs. Staff and resident interviews corroborated that the LPN was frequently absent from the building during his shifts, and the facility lacked documentation or monitoring to address these concerns.