Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for LPNs on six occasions across different dates. Specifically, the facility did not meet the mandated LPN-to-resident ratios during various shifts, including the day, evening, and overnight shifts. For instance, on July 16, 2024, the facility had a census of 115 residents, necessitating 23.00 hours of LPN care during the overnight shift, but only 16.00 hours were provided. Similar deficiencies were noted on other dates, such as July 17, 2024, when 23.80 hours were required, but only 16.00 hours were provided, and on July 20, 2024, when the day shift required 39.36 hours, but only 32.00 hours were provided. The deficiency was confirmed through a review of nursing staff schedules, punch reports, and interviews with staff. The Nursing Home Administrator acknowledged that the required staffing ratios were not met on the specified dates. The report highlights that the facility's failure to provide the mandated LPN hours affected multiple shifts and dates, indicating a pattern of non-compliance with staffing regulations.
Plan Of Correction
No specific residents were identified. No residents were negatively impacted by the LPN ratios. An audit was completed of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator has reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit LPN ratios 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.