LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on nine shifts out of 57 reviewed. Specifically, the facility did not provide the minimum LPN staffing levels on various dates in December 2024. On December 14, 15, 21, and 25, the day shift was understaffed, with fewer LPNs than required for the resident census. The evening shift on December 24 and the night shifts on December 20, 25, 27, and 28 also had insufficient LPN staffing. The facility's staffing records confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall. 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. 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. 5. Date of compliance will be January 21, 2025.