LPN Staffing Deficiency on Evening and Night Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the evening and night shifts over a 21-day period. Specifically, on one evening shift, the facility did not provide the minimum of one LPN per 30 residents, and on three night shifts, the facility did not provide the minimum of one LPN per 40 residents. The review of nursing time schedules and facility census data from January 14, 2025, through February 3, 2025, revealed these staffing shortages. On January 25, 2025, during the evening shift, the facility had a census of 80 residents but only provided 21.25 hours of LPN coverage instead of the required 21.33 hours. During the night shifts on January 20, 22, and 25, 2025, the facility also failed to meet the required LPN hours based on the census. The Nursing Home Administrator confirmed these deficiencies during an interview on February 6, 2025.
Plan Of Correction
1. The facility cannot correct that the LPN staffing ratio was not met on evening shift 1/25/25 and night shift 1/20/25, 1/22/25, 1/25/25. There were no adverse effects to residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.