F0725

E

Lack of Licensed Nurse Coverage on One Wing Leading to Missed Medications

Tybee Island, Georgia Survey Completed on 03-19-2026

Penalty

1 days payment denial

Summary

The facility failed to provide sufficient licensed nursing staff on the [NAME] Wing during the 3:00 PM to 11:00 PM shift on December 25, 2025, resulting in no licensed nurse coverage after approximately 6:00 PM. The facility’s daily staffing document for that date showed no licensed nurse scheduled for the [NAME] Wing on the 3:00 PM to 11:00 PM shift. The scheduler confirmed that no licensed nurses were assigned for that shift on the [NAME] Wing and that she was unable to fill the assignments despite using agency staff and being aware of multiple call-outs. She stated that the DON was notified and did not come in to work the shift, and the Administrator later reported being unaware that there was no nurse on the wing after 6:00 PM.

On December 25, 2025, two nurses (an LPN and an RN) worked the [NAME] Wing day shift and reported that no nurse arrived to relieve them at 3:00 PM. Both nurses stated they notified the scheduler, DON, and Administrator that there was no relief nurse. One nurse reported that the DON told her there was nothing she could do. Both nurses remained on duty until nearly 6:00 PM, then counted the medication cart together, secured the medication keys in the locked medication room or at the nurse’s station, and left the facility, leaving the [NAME] Wing without licensed nurse coverage for the remainder of the evening shift. A regional nurse consultant later confirmed there was no nurse on the [NAME] Wing after 6:00 PM on that date.

Multiple residents with little to no cognitive impairment, as evidenced by BIMS scores of 14 and 15 on their quarterly MDS assessments, reported that there was no nurse available on the [NAME] Wing during the evening of December 25, 2025. One resident stated that there was no nurse after 3:00 PM to give medications, and another resident reported that there had been a couple of days, usually around holidays, when no nurse was available. A resident who returned from an outing with family around 7:00 PM stated there was no nurse working on the [NAME] Wing and that, as a diabetic, he did not receive any medicine until the next day. A grievance/complaint report filed by the DON on December 26, 2025, documented that some residents on the [NAME] Wing reported not receiving their 9:00 PM medications on December 25, 2025, and that the Medical Director was notified.