LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on multiple occasions over a 21-day period from November 20 through December 10, 2024. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on five days, one LPN per 30 residents during the evening shift on two days, and one LPN per 40 residents during the night shift on six days. These deficiencies were identified through a review of nursing schedules, indicating a consistent shortfall in staffing levels required by the regulation effective July 1, 2023.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. 1) The facility cannot retroactively correct the past LPN Ratios. 2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.