LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the regulatory requirements for staffing Licensed Practical Nurses (LPNs) across multiple shifts. 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 review of nursing schedules and staff interviews revealed that the facility did not comply with these staffing ratios for 57 out of 63 shifts reviewed. On specific dates, the facility's census data indicated a need for a certain number of LPNs based on the number of residents, but the actual staffing levels fell short. For instance, on 09/03/2024, the evening shift required 7.76 LPNs for a census of 194 residents, but only 7.30 LPNs were scheduled. Similarly, on 12/13/2024, the night shift required 4.58 LPNs for a census of 183 residents, but only 3.00 LPNs were available. In each instance, there were no additional higher-level staff available to compensate for the deficiency. The consistent shortfall in LPN staffing across various shifts and dates indicates a systemic issue in maintaining the required staffing levels. This deficiency was observed over several months, affecting both day and night shifts, and was not mitigated by the presence of additional higher-level staff. The lack of adequate staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks resulting from the staffing deficiencies.
Plan Of Correction
There were no adverse effects to the residents in the center as a result of the Licensed Practical Nurse ratios for the night shift staffing during the months of May, September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed nurse ratio of one licensed nurse per 25 residents on day shift, 30 residents on evening shift, and 40 residents on night shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.