LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts over a 21-day review period. Specifically, the facility did not provide the minimum required number of LPNs per resident on the day, evening, and overnight shifts. On the day shift, there were no LPNs present when 3.08 to 3.16 were required for a census ranging from 77 to 79 residents. Similarly, the evening shift also had no LPNs present when 2.57 to 2.63 were required for the same census range. The overnight shift was also understaffed, with only 1.07 LPNs working when 1.90 to 1.98 were required, and on several nights, no LPNs were present at all. The Nursing Home Administrator confirmed during an interview that the facility was unable to provide the required staffing information and acknowledged the failure to meet the minimum LPN ratio requirements. This deficiency was identified through a review of the facility's nursing staffing documents and staff interviews, highlighting a significant gap in meeting regulatory staffing standards for LPNs during the specified periods.
Plan Of Correction
The facility must maintain the minimum of one LPN for every 25 residents during the day shift, a minimum of one LPN for every 30 residents for the evening shift, and a minimum of one LPN for every 40 residents for the overnight shift. To ensure that this regulatory requirement is met, the following action plan will be implemented: Education was provided to the scheduler on February 4, 2025, and will be presented to the Director of Nursing by the Administrator to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses. The LPN schedule will be reviewed by the scheduler and Director of Nursing to ensure that LPN ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Assistant Director of Nursing and/or the Scheduler are responsible for handling call-offs on the off shifts and weekends. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that LPN ratios are met for the day, evening, and overnight shifts. The audit will be monitored by the Administrator or Designee. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.