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P5530

Failure to Meet LPN Staffing Ratios Overnight

Wynnewood, Pennsylvania Survey Completed on 12-03-2024

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 maintain the required staffing ratios for Licensed Practical Nurses (LPNs) during the overnight shift on one of the 63 shifts reviewed. Specifically, on October 20, 2024, the facility had a census of 176 residents, necessitating 35.20 hours of care by LPNs for the 11:00 p.m. to 7:00 a.m. shift. However, the review of nursing time schedules revealed that only 33.74 hours of care were provided by LPNs, falling short of the required staffing ratio. This deficiency was identified during a review of nursing staff schedules and interviews with staff, and it was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024.

Plan Of Correction

The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios on the nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.

See complete original report
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