LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum LPN staffing levels on 24 out of 63 shifts reviewed. The deficiency was noted on various dates, including December 24, 2024, through January 13, 2025, where the number of LPNs on duty was consistently below the required ratios for the day, evening, and night shifts based on the facility's census. For instance, on December 24, 2024, the facility had only 1 LPN on the day shift when 1.36 were required for a census of 34 residents. Similarly, on January 1, 2025, the night shift had only 0.25 LPNs when 1 was required for a census of 33 residents. The report indicates that no additional higher-level staff were available to compensate for these deficiencies, highlighting a consistent shortfall in meeting the regulatory staffing requirements.
Plan Of Correction
1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates. 2. A wide audit of the facility was completed to ensure ratios were met. Recruitment initiatives were increased, LPN sign on bonuses, and wages are competitive with surrounding areas. 3. The DON and Recruitment were re-educated on ensuring that nursing care ratios are provided, and that the facility is actively recruiting LPNs. The DON will review census and schedule daily to ensure adequate staffing of LPN's. 4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.