Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two specific shifts out of 21 shifts reviewed. On January 23, 2025, during the day shift, the facility had 3.03 LPNs instead of the required 3.72 for a census of 93 residents. Similarly, on January 26, 2025, during the night shift, the facility had 2.28 LPNs instead of the required 2.35 for a census of 94 residents. There were no additional higher-level staff available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
The facility is unable to retroactively correct the cited issue. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing, and Nursing Home Administrator to review the current day LPN staffing ratios and upcoming week to ensure appropriate staffing levels for LPN staffing ratios for each shift. The facility is focusing on retention of existing LPNs and recruitment of new LPN nurses through the efforts of the Human Resources manager and the Administrator working on the facility recruitment and retention plan to maintain required state ratios. If the projected staffing ratios do not meet minimum, then the facility will reach out to current staff and local staffing agencies using as needed bonuses to enlist staff or agency staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Daily audits of the schedules will be conducted for 7 days for 2 weeks and weekly for 2 months. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state ratio can be met through the hiring and retention plan.