F0727

F

Failure to Maintain a Full-Time, Dedicated DON While DON Also Covered Multiple Clinical Roles

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a full-time, dedicated Director of Nursing (DON) as required, particularly when the census exceeded 60 residents. Interviews and record reviews showed that from late July to late October and again from late November to the survey date, the facility did not have a full-time DON. Instead, the individual designated as DON was functioning in multiple roles, including Interim DON, Clinical Manager/floor nurse on the ventilator/trach unit, Infection Preventionist (IP), wound care supervisor, and lead educator. The facility assessment documented that the facility staffs a full-time DON and a full-time ventilator unit lead nurse, but in practice, one person was performing both of these roles along with additional responsibilities.

During interviews, the Interim DON reported working only part of the week on DON duties and the remainder as Clinical Manager/floor nurse on the vent/trach unit, including every other weekend on the unit. The Interim DON estimated dedicating approximately 30–32 hours per week to DON responsibilities and confirmed also serving as the facility IP, spending Mondays on infection prevention while multitasking with DON or floor nurse duties. The Assistant DON stated that coverage for the DON role on days when the Interim DON worked the floor was handled informally through verbal communication and that the Assistant DON was not formally scheduled as acting DON. The Nursing Home Administrator acknowledged that the requirement is to have a full-time DON and confirmed that the Interim DON was splitting time between DON duties, floor nursing, and IP responsibilities.

Payroll-Based Journal (PBJ) data provided by the facility showed that while weekly reported DON hours often exceeded 40 hours, they were spread across long individual days and weekends rather than reflecting a consistent, full-time, Monday–Friday DON presence. The PBJ hours also did not align with the schedule pattern described by the Administrator and Interim DON, raising concerns about the accuracy of the reported DON hours. The surveyor noted that the lack of a full-time, dedicated DON, combined with the Interim DON’s multiple concurrent roles (DON, vent unit lead nurse, IP, wound supervisor, and educator), meant that these roles could not be adequately performed within the hours worked and created a reasonable likelihood that this contributed to various clinical issues identified during the survey in areas such as care planning, infection control, wound care, staffing, tube feeding, catheter care, and staff competencies. The deficiency was cited as a Class B State citation related to failure to meet required DON staffing.

The Medical Director and a nurse practitioner involved with the ventilator unit both confirmed that they understood the Interim DON to be the DON but were not aware of the extent to which the DON was also working on the floor and serving as IP. The nurse practitioner stated that the DON position is typically full time plus more and acknowledged understanding a concern if the DON had that many responsibilities. The Administrator provided a timeline showing that after the prior DON resigned, the Interim DON assumed the DON role while continuing other duties, a new DON was briefly hired and then went on leave and was terminated, and the Interim DON again resumed the DON role while still functioning as Clinical Manager/floor nurse, IP, and wound supervisor. Throughout this period, the facility’s average daily census was in the high 50s to mid-60s, exceeding the threshold at which the surveyor stated a full-time, dedicated DON is required.