LPN Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios as mandated by regulations effective July 1, 2023. During the day shift, the facility did not provide the minimum of one LPN per 25 residents on six out of the 21 days reviewed. Specific instances include November 12, 2024, with a census of 106 residents and only 3.93 LPNs scheduled, when 4.24 were required, and November 25, 2024, with a census of 99 residents and only 3.51 LPNs scheduled, when 3.96 were required. Similar deficiencies were noted on other days within the reviewed period. The evening and overnight shifts also experienced staffing shortages. During the evening shift, the facility failed to provide one LPN per 30 residents on nine out of the 21 days reviewed. For example, on November 25, 2024, with a census of 99 residents, only 2.66 LPNs were scheduled, while 3.30 were required. The overnight shift was deficient on five days, such as November 26, 2024, with a census of 104 residents and only 2.09 LPNs scheduled, when 2.60 were required. These findings were confirmed by the Nursing Home Administrator during a meeting on December 9, 2024.
Plan Of Correction
1. While the facility cannot retroactively correct the citations. 2. Facility has hired 2 LPN's and 2 RN's since receiving deficiency. 3. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the LPN to resident ratios. 4. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 5. The Facility has updated all job postings to attract more staff to fill the LPN open positions. 6. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the LPN to resident ratios. 7. The Scheduling Manager/Designee will randomly audit the nurse aide to resident ratios weekly x's 3 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI Committee.