The director worked as a floor nurse four times between August and September while the facility housed between 116 and 121 residents. Federal regulations prohibit nursing directors from working as charge nurses when facilities average 60 or more residents daily.
On August 3, the director worked a four-hour shift from 2:00 PM to 6:00 PM as charge nurse in the 100 hall while the facility housed 118 residents. Eight days later, he worked a full 12-hour shift from 6:00 AM to 6:00 PM in the 300 hall with 121 residents in the building.
The pattern continued in September. On September 8, the director again worked 12 hours in the 100 hall with 116 residents present. Six days later, he pulled another 12-hour shift in the 300 hall, again with 116 residents.
"When he worked as a floor nurse he was not able to perform all of his responsibilities as a DON," the director told inspectors on September 25.
The assistant director of nursing described the director as "a last resort to fill in as a charge nurse if they could not find anyone else." She explained that charge nurses oversee residents on individual halls, with typically five working during day shifts and three during nights.
The administrator confirmed the director "has filled in as a charge nurse on the halls a few times" and was "the last person on the list to call when a charge nurse was needed." The administrator said they never scheduled the director for floor duty ahead of time.
"If the DON was scheduled on a daily basis to work as a charge nurse they would not be able to perform their DON duties effectively," the administrator told inspectors.
The director said he typically learned about staffing shortages about an hour before he needed to report to the facility. He was never scheduled for floor work in advance.
When inspectors asked for facility policies governing when the director of nursing could work as a charge nurse, the administrator said no such policy existed.
The violation occurred during a period of apparent chronic understaffing. The assistant director described the director's floor work as happening "when they were short-staffed" and said she had personally witnessed him working as a charge nurse.
Federal regulations require nursing directors to focus on supervisory duties rather than direct patient care when facilities house 60 or more residents. The rule aims to ensure adequate oversight of nursing operations and prevent the division of attention that could compromise resident safety.
San Rafael Nursing operates on Sunnybrook Road in Corpus Christi and was cited for minimal harm with few residents affected. The facility's daily census during the violation period ranged from 116 to 121 residents, nearly double the 60-resident threshold that triggers the prohibition.
The director's dual role created a conflict between administrative oversight and hands-on patient care. While working 12-hour shifts on patient halls, he could not simultaneously monitor facility-wide nursing operations, review care plans, or address systemic issues that might affect resident safety.
The assistant director's description of the director as a "last resort" suggests the facility struggled to maintain adequate charge nurse staffing throughout the summer and early fall. Rather than addressing underlying staffing problems, management repeatedly called on the director to fill gaps in direct care coverage.
The administrator's acknowledgment that regular floor scheduling would prevent effective DON performance highlights the fundamental conflict created by the practice. Yet the facility continued using the director for emergency staffing without establishing policies to govern when such assignments were appropriate.
The absence of written policies regarding the director's floor duties left staff without clear guidance about when federal regulations might be violated. The administrator's admission that no such policies existed suggests the facility operated without considering federal staffing requirements.
The director's hour-long notice before emergency shifts indicates the facility's staffing challenges were ongoing rather than isolated incidents. This pattern suggests systemic problems with nurse recruitment or retention that forced management to rely on inappropriate staffing solutions.
The four documented violations occurred over a six-week period, suggesting the practice was routine rather than exceptional. Each incident required the director to abandon supervisory responsibilities for direct patient care, potentially leaving other aspects of nursing operations without adequate oversight.
Federal inspectors found the practice could lead to "dividing the DON's attention, preventing them from performing duties assigned to the DON leading to possible harm to a resident."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Rafael Nursing and Rehabiliation from 2025-12-01 including all violations, facility responses, and corrective action plans.
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