Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure RN coverage for eight consecutive hours per day, seven days per week for its 20 residents. Review of the PBJ Staffing Data Report for a specified quarter showed the metric was suppressed because the PBJ data had not been submitted. A review of the direct care staff schedule over several months, which used coded letters and colors to indicate shift times, requests off, and call-outs, identified seven specific days without the required 8 hours of RN coverage. On those dates, the schedule did not reflect an RN on duty for the full required period. During interviews, the administrator stated that the DON was salaried and therefore not counted on the schedule. The DON explained that call-ins were first handled by the nurse attempting to find coverage, then escalated to the DON, who would attempt to find coverage or personally work the shift if no one else was available. When asked to verify RN coverage for the identified dates, the DON stated they had covered several of those days but had no timecards to verify their hours, and acknowledged that on one of the days there were only 6 RN hours and on another day there were no RN hours at all. The administrator later provided a handwritten note stating the DON only clocks in when working on the floor and is otherwise present for 8 hours per shift when on call and no coverage, but the facility did not provide timecards to substantiate RN hours for the deficient dates.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.