Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on multiple occasions over a 21-day period in December 2024. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on six days, one LPN per 30 residents during the evening shift on three days, and one LPN per 40 residents during the night shift on eight days. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the facility's inability to meet the staffing requirements on the identified days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff, and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.