LPN Staffing Deficiency on Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on three specific days, as evidenced by a review of nursing time schedules and staff interviews. On December 10, 2024, the facility had a census of 169 residents, necessitating 5.63 LPNs for the evening shift, but only 4.95 LPNs were available. Similarly, on January 19, 2025, with a census of 166 residents, 5.53 LPNs were required, yet only 5.50 LPNs were present. On January 25, 2025, the overnight shift required 3.98 LPNs for a census of 159 residents, but only 3.06 LPNs were available. In each instance, there were no additional higher-level staff available to compensate for the deficiency. The Nursing Home Administrator confirmed during an interview on February 7, 2025, that the facility did not provide the minimum required number of LPNs per 30 residents on the evening shift and per 40 residents on the overnight shift on the specified days. This failure to meet staffing regulations occurred on three out of 21 days reviewed, indicating a lapse in maintaining adequate nursing services as per the regulatory requirements effective from July 1, 2023.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 12/10/24, 1/19/25, and 1/25/25. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on the New July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit licensed nurses through all platforms. Audits of licensed nursing staff will be completed weekly x4 by the NHA/Designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.