LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across various shifts over a 21-day review period. Specifically, the facility did not maintain the minimum staffing ratio of one LPN per 25 residents during the day shift on five occasions, one LPN per 30 residents during the evening shift on one occasion, and one LPN per 40 residents during the night shift on twelve occasions. The review of nursing care hours for the weeks of November 24-30, 2024, December 15-21, 2024, and January 1-7, 2025, revealed specific dates where the staffing levels were below the required minimums, with the census and the number of LPNs provided falling short of the regulatory requirements. The deficiency was confirmed through an interview with the nursing home administrator and the director of nursing on January 8, 2025. The interview corroborated the findings from the review of nursing staffing hours, indicating a consistent failure to meet the mandated LPN-to-resident ratios. This deficiency highlights a significant lapse in ensuring adequate nursing care coverage, which is essential for maintaining the quality of care and safety of the residents.
Plan Of Correction
Licensure Nursing Services (LPN Staff Ratios) The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency within. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. There were no adverse effects to the residents of our facility as a result of decreased staffing ratios. 2. The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for LPN to resident staffing ratios by the Quality Clinical Consultant/designee. 3. Staffing meetings will be held 5 days a week to review LPN ratios from the previous day and the projected LPN staff ratios for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state requirement for LPNs, then the facility will reach out to current staff and staffing agencies to meet the minimum requirement. The facility will continue to recruit staff through all platforms. 4. Audits of LPN staff ratios will be completed randomly by the DON/designee to ensure LPN staff ratios meet the state minimums. Results of the audits with trends will be reported through QA&A. 5. Date of Compliance February 20, 2025.