LPN Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one of the 21 shifts reviewed. Specifically, on January 21, 2025, during the night shift, the facility had 2.00 LPNs instead of the required 2.13 for a census of 101 residents. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulations effective July 1, 2023.
Plan Of Correction
The facility cannot retroactively correct the past LPN Ratios. Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of one LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts. To prevent this from reoccurring, the RDCS re-educated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.