LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for Licensed Practical Nurses (LPNs) during both daylight and overnight shifts over a three-week period. Specifically, the facility did not provide the required minimum of one LPN per 25 residents during the day shift on two occasions and failed to provide one LPN per 40 residents during the overnight shift on 14 occasions. This deficiency was identified through a review of the nursing time schedules and was corroborated by interviews with residents and the Director of Nursing (DON). Residents expressed concerns about staffing shortages, with one resident noting that the facility was "a little short on staff in the evenings," and another resident confirming that staff shortages occurred at times. The DON acknowledged the failure to meet the staffing requirements, confirming the specific dates when the facility did not have the mandated number of LPNs on duty. These findings highlight the facility's non-compliance with the staffing regulations effective from July 1, 2023.
Plan Of Correction
The facility cannot correct that LPN staffing ratios were not met on 11/21/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/26/24, 11/28/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/6/24, 12/8/24, 12/9/24, 12/10/24. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.