LPN Staffing Deficiency on Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on seven out of twenty-one reviewed shifts. Specifically, the night shifts on January 30, January 31, February 1, February 2, February 3, and February 4, 2025, did not have the minimum required LPN staffing based on the facility's census. For instance, on January 30 and 31, only one LPN was present on the night shift, whereas the required staffing was 1.2 LPNs for a census of 48 residents. Similarly, on February 1, the evening shift had 1.56 LPNs instead of the required 1.57 for a census of 47. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the shortfall in meeting the required LPN to resident ratios on the specified dates. No additional higher-level staff were available to compensate for this deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.