Failure to Maintain Required LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six out of 21 days reviewed. Specifically, the facility did not meet the mandated LPN-to-resident ratios during the day, evening, and overnight shifts on January 24, 25, 26, 27, 28, and 29, 2025. The regulation requires 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's staffing schedules and punch reports indicated that these ratios were not met, leading to a deficiency in nursing services. On January 24, 2025, the facility's census was 163, necessitating 34.64 hours of LPN care during the overnight shift, but only 34.00 hours were provided. Similarly, on January 25, 2025, the evening shift required 46.18 hours of LPN care, but only 25.50 hours were provided. On January 26, 2025, with a census of 162, the overnight shift required 34.43 hours, but only 24.00 hours were provided. The pattern continued on January 27, 28, and 29, 2025, where the required LPN hours were not met, indicating a consistent failure to adhere to the staffing regulations set forth for the facility.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios on the evening shift and the night shift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.