LPN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios as per the regulation effective July 1, 2023. During the review of nursing staffing hours from December 26, 2024, to January 2, 2025, it was found that the facility did not maintain the minimum staffing levels on several occasions. Specifically, on December 29, 2024, the day shift had 4.00 LPNs for a census of 103 residents, falling short of the required 4.12 LPNs. Additionally, the overnight shift was understaffed on five of the eight days reviewed, with the number of LPNs consistently below the required ratio for the resident census. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these staffing deficiencies.
Plan Of Correction
The Facility is unable to correct past LPN ratios. Nursing staff will be educated on the Facility Attendance Policy. Facility ancillary Nursing staff assist in filling open shifts. The Facility continues to actively recruit for open LPN positions using online systems, fliers, and outside recruiters. The Facility also uses Agency staff to fill open shifts. Agency LPN rates were recently adjusted in an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open shifts. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary LPN ratios. The DON/Designee will audit LPN ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.