LPN Staffing Deficiency on Overnight Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Licensed Practical Nurse (LPN) per 40 residents on the overnight shift. This deficiency was identified during a review of nursing staffing documents and confirmed through staff interviews. Specifically, on the night of October 25, 2024, the facility had a census of 58 residents but only 1.32 LPNs were on duty, whereas 1.45 LPNs were required to meet the minimum staffing ratio. The Assistant Director of Nursing confirmed the shortfall in staffing during an interview conducted on December 2, 2024.
Plan Of Correction
Plan of Correction: 1. The facility cannot correct that LPN staffing ratios that were not met during the overnight shift on one of 21 days (10/25/24). However, we will educate staff on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will ensure that LPN staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at the daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/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 two months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Employee Retention survey will be taken from 12/27/24 through 01/06/2025 to evaluate staffing concerns and reasons for call-offs. To prevent further call off concerns in order to achieve needed staff ratios daily. 6. ADON and DON will ensure staffing levels meet direct care requirements and report to Director every day with needs or call-offs.