F0725

J

Failure to Assign Charge Nurse Leads to Impaired LPN and Missed Medications

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure sufficient licensed nursing supervision and coordination of care when no licensed nurse was designated to serve as charge nurse for the night shift beginning at 7:00 PM on 12/29/25. The scheduled charge nurse called in sick, and the daily staffing schedule showed the supervisor for the 7:00 PM–7:00 AM shift marked out with “vacation” and no replacement charge nurse indicated. As a result, there was no nurse assigned to supervise staff, coordinate care, or respond to unsafe conditions on that shift, despite facility policy requiring a licensed nurse to be designated as charge nurse on each tour of duty.

During this unsupervised shift, an LPN assigned to Station B reported being ill, later stating in a counseling/discipline report that they had a temperature of 101 degrees and a blood sugar of 67, and that they did not remember the events. The facility’s investigation and camera footage review showed that this LPN remained on duty from 7:00 PM until approximately 3:00 AM while impaired and unable to safely perform nursing duties. The LPN was observed at the nurse’s station for about two hours, then pushing the medication cart into the hallway, staring at the computer for a long time, swaying and almost falling, stumbling, and appearing to be under the influence of something. The LPN fumbled through the medication cart, pulled medication cards and stared at them for minutes, fell asleep at the medication cart in the dining room with their head resting on the cart, and awoke only when the cart began to roll away. A resident in the dining room witnessed this incident, and nursing assistants repeatedly woke the LPN and placed a chair behind them after they nearly fell while sleeping on the cart.

Certified nurse assistants on the unit reported that around 8:00 PM the LPN began falling asleep standing up, crying loudly, moaning, and going back and forth to the bathroom frequently. They described the LPN leaning over the medication cart with eyes closed, legs giving out, and falling asleep on the counter in the nurse’s station and at the open medication cart. Staff stated that no residents on that station received their medications as ordered, that residents repeatedly called for their medications, and that the LPN could not stay awake to pull or pass medications, even with assistance from the nurse on the other station who tried to help with the medication pass. One CNA reported the LPN kept falling asleep while trying to sign the narcotics book and refused an ambulance when staff tried to get emergency help. Medication administration audit reports for Station B showed 25 residents with medications documented as missed and 5 residents with medications documented as administered late during this shift. The DON and Administrator later confirmed that there was no designated charge nurse on duty, that the impaired LPN remained responsible for resident care and medication administration until a replacement nurse arrived around 3:00 AM, and that the DON was not notified of the situation until approximately 1:30 AM.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created that indicate the staff member who tested the temperature of the coffee, the time, and the date.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Staff will be trained on accidents and supervision including implementing immediate interventions.
• Staff will be trained on abuse and neglect reporting and investigation.
• Staff will be trained on the hot liquids policy.
• Staff will be trained on notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
• Staff will be trained on charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• The Facility Assignment Grid was updated to include assignment for a designated charge nurse.
• Staff will be trained on medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• The Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the charge nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• Emergency Quality Assessment and Assurance Committee Meeting held.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency that she works for and is not allowed to work at this facility.