Facility Fails to Meet LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the state-mandated minimum staffing requirements for Licensed Practical Nurses (LPNs) across multiple shifts. Specifically, the facility did not provide the required number of LPNs during the day, evening, and night shifts on several occasions between November 24, 2024, and December 31, 2024. The deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that the facility consistently fell short of the required LPN staffing levels. On several nights, the facility had no LPNs on duty, despite the census data indicating the need for at least one LPN. For instance, on November 24, 2024, the facility census was 36, necessitating 1.0 LPNs on the night shift, yet only 0.5 LPNs were present. Similarly, on November 25 and 26, 2024, the facility census required 1.0 LPNs, but no LPNs were on duty. This pattern of insufficient staffing continued on multiple nights, with no additional higher-level staff available to compensate for the deficiency. The deficiency was further compounded by inadequate staffing during the day and evening shifts. On several occasions, the number of LPNs on duty was below the required level based on the facility census. For example, on November 29, 2024, the day shift required 1.32 LPNs, but only 1.00 LPN was present. The facility's failure to meet the staffing requirements was confirmed by the Nursing Home Administrator during an interview on January 2, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.