LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the facility did not meet these staffing requirements on several occasions. Specifically, on one day, the day shift was understaffed with 3.19 LPN Full Time Equivalents (FTE) present instead of the required 3.88 for 97 residents. Similarly, the evening shift on the same day had 8.00 LPN FTE present instead of the required 8.82. The night shift was particularly affected, with staffing shortages on 13 out of 21 days, where the number of LPN FTE present consistently fell short of the required numbers for the census on those days.
Plan Of Correction
The facility will continue to maintain the required LPN ratios (1-25, 1-30, 1-40). To increase staffing, the facility will call in off-duty staff, call sister facilities, or utilize agency staff as needed. Additionally, the facility will acquire new agency partnerships and offer bonuses to current staff to ensure sufficient nursing staffing. The RDCS educated NHA/DON/scheduler on the LPN ratio requirements, ensuring sufficient nursing staff (1-25, 1-30, 1-40). To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily x 5x weekly x 4 weeks, then 1x daily x 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.