LPN Staffing Deficiency on Overnight Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one LPN per 40 residents during the overnight shift. This deficiency was identified during a review of nursing staffing hours and confirmed through a staff interview. Specifically, on the overnight shift of January 27 into 28, 2025, the facility scheduled only 2.63 LPNs for a resident census of 109, which required 2.73 LPNs. This shortage was acknowledged by Employee 5, the scheduler, during an interview conducted on January 31, 2025.
Plan Of Correction
The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of LPN staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.