The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
RN staffing was not provided for at least 8 consecutive hours a day, 7 days a week. An LVN stated there were times when no RN was available, and the DSD confirmed the facility did not consistently schedule an RN every day, including weekends. Record review showed multiple days with no RN listed on the staffing report, and the DON stated the facility had difficulty maintaining RN coverage and had no policy addressing RN staffing.
The facility failed to follow its staffing policy when no RN was present for the required 8 consecutive hours in a 24-hour period. Review of TSNH records showed multiple days with 0 RN hours despite resident census levels of 52 to 55, and the DON and ADON confirmed the RN was not covering the floor on those dates.
The facility failed to ensure an RN was on duty for 8 consecutive hours a day, 7 days a week. Review of staffing sign-in sheets showed no RN available for a consecutive 8-hour shift on multiple dates, and the DSD confirmed there was no RN present in the building for 8 hours on those days. The facility policy stated that F727 requires an RN onsite at least 8 consecutive hours daily.
The facility failed to ensure an RN was on duty for 8 hours a day, 7 days a week. During record review with the DSD, the clock-in log showed multiple days when no RN was present in the building for the required 8 hours, despite the facility policy stating an RN must provide services at least 8 consecutive hours every 24 hours.
The facility failed to maintain a full-time RN DON or appoint an acting DON after the previous DON resigned, despite having a census of 71 residents. The administrator and multiple staff members, including RNs, LVNs, and the MDS coordinator, confirmed that there was no DON or interim DON in place and that staff instead relied on shift RNs, an LVN DSD, and a corporate RN available by phone and occasional visits for clinical and staffing issues. Facility policy and professional references reviewed by surveyors required that nursing services be under the direct supervision of a full-time RN DON responsible for managing nursing services, overseeing licensed nurse schedules, and ensuring care and documentation follow resident assessments and care plans, and staff acknowledged that the absence of a DON could lead to potential medication errors, improper assessments, and non-compliance with policies and procedures.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week. Staff interviews showed inconsistent understanding of RN presence, and the Administrator stated the facility had not had an RN working on the floor consistently and relied on the DON for coverage. Time sheets for two RNs showed many days when no RN worked in the facility besides the DON.
The facility did not have a full-time RN serving as DON for an extended period, instead relying on RN consultants who visited part-time and floor RNs/LVNs to provide oversight. This was contrary to facility policy, which requires a full-time DON to oversee nursing services and ensure regulatory compliance.
RN Coverage Not Scheduled as Required: Facility RN staffing records showed no RN scheduled for several shifts when the DON was off, and the DON confirmed coverage was instead provided by RNs from the hospital side of the facility down the hall. The DON stated LVNs could get help from an RN from the hospital side and noted the facility would need to apply for the federal waiver for RN coverage.
Failure to Maintain Required RN Coverage: The facility failed to ensure RN coverage for 8 consecutive hours on multiple days when the scheduled registry RN called off or did not show up and the DON was on vacation. The DSD and DON confirmed there was no RN coverage on those dates, and the DON stated the facility assessment required one RN for 8 hours per day and that the facility did not have a nursing services policy or sufficient staffing.
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