Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three specific shifts out of 21 reviewed. On January 25, 2025, the night shift had only 2.72 LPNs instead of the required 2.88 for a census of 115 residents. On January 26, 2025, the day shift had 3.59 LPNs instead of the required 4.56 for a census of 114 residents. On January 27, 2025, the day shift had 4.19 LPNs instead of the required 4.52 for a census of 113 residents. There were no additional higher-level staff available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.