Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three shifts out of 21 reviewed, as evidenced by a review of the facility's weekly staffing records. On January 7, 2025, the evening shift had only 1.87 LPNs instead of the required 2.93 for a census of 88 residents. On January 8, 2025, the night shift had 0.87 LPNs instead of the required 2.2, and on January 9, 2025, the night shift had 1.03 LPNs instead of the required 2.2 for the same census. No additional higher-level staff were 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
The facility cannot retroactively correct the LPN ratios. The facility focuses on retention of existing LPNs and recruitment of new LPNs through the efforts of the retention events and staffing meetings. Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting LPN ratios. The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be reviewed x 2 months at monthly QAPI.