LPN Staffing Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, on June 29, July 2, 4, and 5, 2024, and February 4 and 6, 2025, the facility did not meet these staffing requirements during the evening shifts. The census data indicated that the number of LPN hours required was not met, and there were no additional higher-level staff available to compensate for the deficiency. On June 29, 2024, the facility had a census of 94 residents, requiring 25.07 hours of LPN care, but only 24.00 hours were provided. Similar deficiencies were noted on July 2, 4, and 5, 2024, and February 4 and 6, 2025, where the required LPN hours were not met, with the most significant shortfall occurring on July 5, 2024, when only 16.00 hours of LPN care were provided against a requirement of 24.27 hours. The Nursing Home Administrator confirmed these deficiencies during a review of staffing calculations, nursing staff schedules, and punch reports on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.