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P5530

LPN Staffing Deficiency During Night Shift

Darby, Pennsylvania Survey Completed on 01-09-2025

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 regulatory requirement of providing a minimum of one LPN per 40 residents during the night shift on four specific dates. The facility census data indicated that on each of these dates, the census was 92, necessitating 2.30 LPNs for adequate coverage. However, the nursing time schedules revealed that the facility provided fewer LPNs than required: 2.06 LPNs on 11/23/2024, 2.14 LPNs on 11/24/2024, 2.23 LPNs on 11/28/2024, and 1.45 LPNs on 11/29/2024. There were no additional higher-level staff available to compensate for this deficiency, leading to non-compliance with the staffing regulation.

Plan Of Correction

Our Staffing Coordinator in conjunction with our Director of Nursing will monitor our daily census and prepare for any increase in census throughout the day. They will continue to use the staffing tool provided by DOH to ensure compliance with all PPDs and staffing ratios. This tool will be monitored by the Director of Nursing on a daily basis.

See complete original report
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