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P5530

LPN Staffing Shortages in Facility

North Huntingdon, Pennsylvania Survey Completed on 01-31-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on multiple occasions across different shifts. Specifically, the facility did not provide the minimum number of LPNs per residents as mandated by regulations on 5 out of 21 days for both the day and evening shifts, and on 3 out of 21 days for the night shift. The review of nursing schedules and census information revealed that on certain days, the actual LPN hours were below the required hours based on the resident census. For instance, on the day shift of 11/09/24, with a census of 106 residents, only 32 actual LPN hours were provided against the required 33.92 hours. Similar shortages were noted on other specified dates for the evening and night shifts. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the facility's failure to meet the staffing requirements on the specified days and shifts.

Plan Of Correction

The facility will ensure state-required LPN ratios are met for all shifts. The facility cannot correct that LPN staffing ratios were not met on the cited dates. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

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