LPN Staffing Shortage During Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift on two specific days. A review of the nursing time schedules and facility census data from December 8, 2024, through December 28, 2024, revealed that on December 10 and December 15, 2024, the facility did not have the required number of LPNs on duty during the night shift. Specifically, the facility had a census of 91 residents, necessitating 2.28 full-time equivalent (FTE) LPNs, but only 2.19 and 2.06 FTEs were present on the respective days. The Assistant Director of Nursing confirmed this staffing shortfall during an interview on January 7, 2025, acknowledging the failure to provide the required LPN coverage without any additional higher-level staff to compensate for the deficiency.
Plan Of Correction
1. The facility will ensure state-required LPN ratios are met during the overnight shift. The facility cannot correct that LPN staffing ratios were not met on the overnight shift on 12/10/24 & 12/15/24. 2. The facility will ensure that the LPN staffing ratio of 1:40 are met during the overnight shift. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5530 and ensuring LPN staffing ratios are met during the overnight shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facilities projections to meet LPN ratios on the overnight shift fall below required ratios due to call offs, No Call No Shows etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure LPN staffing ratios are being met during the overnight shift. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25.