LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required Licensed Practical Nurse (LPN) staffing ratio on the day shift for one of the 21 days reviewed. Specifically, on December 1, 2024, the facility had a census of 77 residents but only staffed 3.00 LPNs, whereas 3.80 LPNs were required to meet the regulatory ratio of one LPN per 25 residents. This deficiency was identified through a review of the facility's nursing staffing documents covering several time periods, and it was confirmed during an interview with the Nursing Home Administrator on December 5, 2024, at 9:10 a.m.
Plan Of Correction
The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required licensed practical nurse to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum licensed practical nurse staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate staffing and licensed practical nurse staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets the licensed practical nurse ratio. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of licensed practical nurse staff to resident ratios have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonuses, and mandating when needed. The facility has ads posted on Indeed and is recently advertising our shift differential for licensed practical nurses on second and third shift, with an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.