LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios as mandated by regulations effective July 1, 2023. The regulation requires 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 comply with these staffing requirements on multiple occasions during the review period from January 5 through January 29, 2025. Specifically, the facility was deficient in providing the required number of LPNs during the day shift for four out of 14 days, during the evening shift for 10 out of 21 days, and during the overnight shift for 13 out of 21 days. For instance, on January 8, 2025, the facility had a census of 157 residents, necessitating 6.28 LPNs during the day shift, but only 6.19 LPNs were available. Similarly, on January 6, 2025, the facility required 3.90 LPNs for the overnight shift with a census of 156 residents, but only 2.03 LPNs were present. The deficiency was confirmed through a review of nursing schedules, staffing information, and staff interviews. The Nursing Home Administrator acknowledged the failure to meet the required staffing ratios during an interview on January 30, 2025. No additional higher-level staff were available to compensate for the staffing shortfall, further exacerbating the deficiency.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing licensed practical nurses to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meetings, discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in-house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor licensed practical nurse hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.