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 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.
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.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as required, with multiple days lacking RN coverage for skilled nursing. The Administrator confirmed gaps in RN scheduling and a lack of awareness regarding the requirement for consistent RN coverage.
The facility did not ensure an RN was present for at least eight hours on four days, with some days having no RN coverage at all. This lapse was confirmed by the DON and Administrator, and was not in accordance with facility policy for staffing to meet the needs of a medically fragile population.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required, on multiple occasions. Staff interviews and record reviews confirmed that on several days, no RN was present to provide necessary services, including care for residents with IV therapy or PICC lines. The DON and Administrator acknowledged difficulties in hiring and retaining RNs, and the facility's own policy requiring daily RN coverage was not followed.
The facility did not have a full-time DON to oversee and manage nursing services, as confirmed by staff interviews and record review. The QA nurse, who was the former DON, indicated that the facility was still in the process of hiring for the position, and a consultant was not present during the initial investigation. This resulted in a lack of designated leadership for clinical care and care planning for all residents.
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