LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on the day shift on four specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day. However, on 11/22/24, with a census of 105 residents, only 4.00 LPNs worked when 4.20 were required. On 12/10/24, with 103 residents, 4.00 LPNs worked instead of the required 4.12. On 1/06/25, with 101 residents, 4.00 LPNs worked when 4.04 were needed, and on the same day with 102 residents, 4.00 LPNs worked when 4.06 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on 1/15/25.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Licensed Practical Nurse (LPN) ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Licensed Professional Nurses (LPN), call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing (DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. LPN Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews LPN ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement (QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet LPN needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.