LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required Licensed Practical Nurse (LPN) staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum LPN-to-resident ratios on both the day and overnight shifts during the period from January 8, 2025, to January 21, 2025. On the day shift, the facility was short of the required LPNs on January 15 and January 20, with a census of 107 residents, where 4.28 LPNs were required, but only 4.05 and 4.27 LPNs worked, respectively. On the overnight shift, the facility was deficient on January 11, 12, 13, and 19, with a census of 108 residents requiring 2.70 LPNs, but only 2.13 LPNs worked on the first three dates, and with a census of 107 residents requiring 2.68 LPNs, only 1.07 LPNs worked on January 19. The Nursing Home Administrator confirmed these staffing shortages during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5530 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, director of nursing/DON, staff educator and assistant director of nursing and charge nurses on the state required minimum staffing ratios for licensed practical nurses. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/ designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for licensed practical nurses are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for licenses practical nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required LPN ratio and PPD, interviews scheduled, new hires and orientation date. NHA/designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Licensed Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the resident and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review licenses practical nurse's ratios. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality and performance improvement process. 5. Dates when corrective action will be completed. March 3, 2025